306006175-3-6-2023-22-AS-SHAD-CPNPNU-20230306102830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006175
Report Date: 03/06/2023
Date Signed: 03/06/2023 10:28:41 AM

Document Has Been Signed on 03/06/2023 10:28 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:	HOLY FAMILY GUEST HOME		FACILITY NUMBER:	306006175
ADMINISTRATOR:	DAMICOG, TERESITA		FACILITY TYPE:	740
ADDRESS:	13372 GARDEN GROVE BLVD		TELEPHONE:	(714) 643-0661
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY:	6	CENSUS: 0	DATE:	03/06/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Teresita Damicog		TIME COMPLETED:	10:40 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) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Teresita Damicog, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 04/01/2022. This is a change of ownership with no persons in care. However, AP stated that this is an initial application, the property was vacant prior to AP taking possession, and that AP has no business relationship with the licensee who previously occupied this property. During the inspection, LPA and AP observed the following: Structure. This is a one-story home. Facility is a 3-bedroom, 2-bathroom, 1 story house with a staff break room and an attached garage that is being used for storage. There is a back yard with a patio cover for the residents. Facility telephone number is (714) 591-5097. Resident Bedrooms. The 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. There are no staff bedrooms. There is a staff break room with chairs but no bed. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 106 and 110 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 7 days nonperishable food supply reviewed and AP stated they will obtain 2 days perishable food prior to accepting residents. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the laundry room and under the kitchen sink. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. There are currently no residents or staff. LPA observed storage space for resident and staff files. Fire clearance was approved by Orange County Fire Authority Inspector Ryan Freerks on 10/12/2022. Backyard. Backyard exit gate is operational and unlocked.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: HOLY FAMILY GUEST HOME	FACILITY NUMBER: 306006175
	VISIT DATE: 03/06/2023

NARRATIVE

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Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once the application is approved.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC809 (FAS) - (06/04)

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