306006196-2-1-2023-22-AS-CGUZ-CNMQB8-20230201110109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006196
Report Date: 02/01/2023
Date Signed: 02/01/2023 11:01:25 AM

Document Has Been Signed on 02/01/2023 11:01 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:	GREENTREE GUEST HOME		FACILITY NUMBER:	306006196
ADMINISTRATOR:	GARCIA, ANNA C		FACILITY TYPE:	735
ADDRESS:	12651 GREENTREE AVENUE		TELEPHONE:	(657) 251-0444
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY: 4		CENSUS: 4	DATE:	02/01/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anna Garcia		TIME COMPLETED:	11:15 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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Anna Garcia. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 12/12/2022. Structure: The facility is a one-story home with 4 client bedrooms, 2 bathrooms, living room, kitchen, and an unattached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the kitchen. There is a back yard with two exit gates on each side of the house. There is a shaded seating area in the backyard. No bodies of water observed. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the laundry room.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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: GREENTREE GUEST HOME	FACILITY NUMBER: 306006196
	VISIT DATE: 02/01/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the dining area.

Pool/Jacuzzi:
No bodies of water in facility.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has work out equipment in the patio for client use. Facility will encourage outdoor activities such as walks and basketball.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 08/08/2022.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:

No staff will be living at the facility.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 112.8 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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: GREENTREE GUEST HOME	FACILITY NUMBER: 306006196
	VISIT DATE: 02/01/2023

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Electric four burner stove with 1 oven, 2 refrigerators, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. LPA informed the applicant's representative that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC809 (FAS) - (06/04)

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