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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006272
Report Date: 04/08/2024
Date Signed: 04/08/2024 05:46:23 PM


Document Has Been Signed on 04/08/2024 05:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:COMPASSIONATE CARE HOMEFACILITY NUMBER:
306006272
ADMINISTRATOR:AMBION, GLADYS AFACILITY TYPE:
740
ADDRESS:12141 GILBERT STREETTELEPHONE:
(714) 400-8679
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 5DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Gladys AmbionTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Gladys Ambion and explained the reason for the visit. The Administrator's, Administrator's Certificate expires July 19, 2025. The last emergency disaster (fire) drill took place on March 12, 2024. Facility is a one story home with, 7 bedrooms, 6 bathrooms living room, eat in kitchen, dining room, family room and an attached 3 car garage that is used for storage. There are 2 extra rooms by the garage that are being used as an office. There is also a detached guest house that is currently being used for storage. LPA observed the See Something Say Something Poster posted in the living room. LPA observed the fireplace in the living room is screened. Facility phone number is 657-251-0408. LPA and Administrator toured the facility. LPA observed the kitchen is clean and organized. LPA observed the stove lights unassisted. There is a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen drawer. Soaps and chemicals are kept locked under the kitchen sink. LPA observed the medications are kept locked in a storage cabinet in the kitchen. Smoke detectors/carbon monoxide detectors tested operational. LPA observed the fire extinguishers are fully charged. Hot water in all bathrooms measured 108.3 degrees Fahrenheit. All bathrooms were clean and operational. LPA observed all resident rooms had the required furnishings. LPA observed the inside of the facility is clean and free of obstacles and hazards. LPA and Administrator toured the backyard. No bodies of water observed. LPA observed the detached guest house and storage shed are used for storage. The path to both exit gates on each side of the house are clear and free from obstruction. Both exit gates are latched and operational. No obstacles or hazards observed in the backyard. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA reviewed 5 resident files, no discrepancies observed. LPA reviewed 5 resident medication and medication records, no discrepancies observed. LPA reviewed 3 staff files, no discrepancies observed. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. LPA consulted with Administrator concerning reporting requirements and file requirements. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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