<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006127
Report Date: 09/06/2022
Date Signed: 09/06/2022 09:44:16 AM

Document Has Been Signed on 09/06/2022 09:44 AM - 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:GRACIE'S GUEST HOMEFACILITY NUMBER:
306006127
ADMINISTRATOR:AZNAR, MARY GRACEFACILITY TYPE:
735
ADDRESS:132932 SIEMON AVETELEPHONE:
(714) 727-8741
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 0DATE:
09/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Mary grace AznarTIME COMPLETED:
09:56 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a follow up pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Mary Grace Aznar. An initial application to operate an Adult Residential Facility was received by CCL on 12/21/2021 for a capacity of six non-ambulatory clients.

At 9:32 AM, LPA toured the facility and observed the following:
  • Water temperature measured between 107.4 and 112.2 degrees F.
  • All burners on the cook top are operational.












Facility is ready to be licensed. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1