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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006066
Report Date: 03/08/2022
Date Signed: 03/08/2022 12:21:44 PM


Document Has Been Signed on 03/08/2022 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CALIFORNIA GUEST HOMEFACILITY NUMBER:
306006066
ADMINISTRATOR:CELIS, PRISCILLAFACILITY TYPE:
740
ADDRESS:2840 E QUINCY AVETELEPHONE:
(562) 388-5088
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 5DATE:
03/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Priscilla Celis and Liza De La Cruz TIME COMPLETED:
12:36 PM
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Licensing Program Analyst (LPA) Jerome Haley made an announced visit to this facility to conduct a pre-licensing inspection and Component III orientation. LPA arrived, was greeted and granted entry and stated the purpose of the visit. LPA met with Administrator (AD) Priscilla Celis and Licensee Liza De La Cruz.
About 10:50 AM, LPA Haley began the tour of the interior and exterior of the facility. There were five residents in care and three staff members present at the facility. There are four resident rooms and two staff rooms at the facility. Rooms are equipped with all the necessary requirements: furniture in good repair, clean linen, adequate storage space, and kept free of tripping hazards. Hardwired smoke and carbon monoxide detectors were tested and are operational. Bathrooms were observed to be in good repair, provided with grab bars and nonskid floor mats. Hot water was measured at 110.3 degrees Fahrenheit. Facility has a two day perishable and seven day non-perishable food supply. Medications are locked in the kitchen, and inaccessible to residents in care. Knives and sharp objects are locked in a drawer and inaccessible to the residents. Staff files were locked in a file cabinet near the dining room. The garage has clear walkways and was well organized. The cleaning supplies are kept locked in the garage and inaccessible to residents. LPA observed an emergency supply of food, water, and PPE. Fire extinguisher was mounted and charged. The backyard had a shaded patio area and there was a table with shade and chairs for residents to enjoy. The side exit gate was self closing and self latching. There was a pile of wood and bricks debris in the backyard. LPA advised AD Celis the importance of having the brick and wood debris removed. AD Celis had the wood debris secured in the garage, and the cement bricks removed immediately.
On January 17th, 2022, The Orange County Fire Authority granted the fire clearance for six non-ambulatory residents. During the visit the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.
The Pre-licensing is complete, Component III was waived and the facility does not need any corrections at this time. The license will be granted upon completion of a final review and approval by the Centralized Applications Bureau for final determination. An exit interview was conducted, and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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