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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006184
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:11:14 PM


Document Has Been Signed on 08/08/2023 04:11 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:DIVINE & GUS CARE HOMEFACILITY NUMBER:
306006184
ADMINISTRATOR:SABLAS, DIVINAFACILITY TYPE:
740
ADDRESS:1315 GROTON STTELEPHONE:
(562) 640-1404
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 6DATE:
08/08/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Divina SablasTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Joseph Alejandre conducted an unannounced collateral visit in conjunction with complaint investigation 22-AS-20230802161055 at another licensed facility. LPA was greeted and granted entry into the facility by Administrator Divina Sablas and explained the reason for the visit.

During the visit, LPA met with Resident 1 (R1) to gather information pertaining to complaint #22-AS-20230802161055. Resident agreed to speak with LPA. R1's responsible party was present. R1's responsible party agreed to be interviewed by LPA.

Exit interview conducted and a copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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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