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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006126
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:24:26 PM


Document Has Been Signed on 04/19/2022 04:24 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:RDB GUEST HOMEFACILITY NUMBER:
306006126
ADMINISTRATOR:BANGGALAT, REGIE DANCELFACILITY TYPE:
740
ADDRESS:2351 W. BROADWAYTELEPHONE:
(714) 519-5268
CITY:ANANHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 0DATE:
04/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Regie Dancel Banggalat, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kathrina Chin conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA met with Regie Dancel Banggalat, Administrator. This is a change of location.
The structure is a single story with four bedrooms. Three bedrooms are for residents and one bedroom is for staff. A fire clearance was granted on 4/14/2022 for five (5) non-ambulatory residents and one (1) bedridden resident. The facility submitted a hospice waiver request for 6 residents.

LPA toured the facility, interior and exterior, including all four bedrooms. The hot water temperature was measured in bathroom 1 at 115.2 degrees F. Fire extinguisher was mounted and charged in the dining room area. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors were observed and are operational. There is one locked medication cabinet by the dining area. Toxins and cleaning solutions are stored in the garage. Auditory devices on all the exits are operational. There are two umbrellas providing shade with tables and chairs.

First aid kits are in the medication cabinet by the dining room. The kitchen area was checked. There are non-perishable food supplies and emergency food supplies. LPA observed the theft and loss policy, residents rights, admission agreement, and emergency plans were posted. There is an Ombudsman poster and "Let us know" posted on the wall.

It appears that this facility meets the requirements for licensure. Both the license and the hospice waiver will be granted upon final review and approval from the Central Applications Bureau. An exit interview was conducted, and a copy of this report was given to Regie Dancel Banggalat, Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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