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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006196
Report Date: 02/14/2024
Date Signed: 02/14/2024 11:52:31 AM

Document Has Been Signed on 02/14/2024 11:52 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 HOMEFACILITY NUMBER:
306006196
ADMINISTRATOR:GARCIA, ANNA CFACILITY TYPE:
735
ADDRESS:12651 GREENTREE AVENUETELEPHONE:
(657) 251-0444
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 4CENSUS: 4DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anna GarciaTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Anna Garcia and explained the purpose of the inspection.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

The facility is a one-story home with four client bedrooms, two bathrooms, and an unattached two car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. A supply of extra linen was stored in the hallway storage. The back yard has a shaded sitting area. LPA observed one client present. Per AD, three clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.4-114.0 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated 12/18/23. Disaster drill log indicated last disaster drill was conducted on 1/29/24. Electric stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed four client files and three staff files. LPA interviewed staff and client present.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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