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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090001
Report Date: 05/19/2022
Date Signed: 05/19/2022 05:25:50 PM

Document Has Been Signed on 05/19/2022 05:25 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:SNCH-ELM HOMEFACILITY NUMBER:
306090001
ADMINISTRATOR:LAURA R. RUBIOFACILITY TYPE:
735
ADDRESS:1728 E. ELM ST.TELEPHONE:
(714) 772-7298
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 3DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alma PayumoTIME COMPLETED:
10:55 AM
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Licensing Program Analysts (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by staff Wendale Payumo and granted entry into the facility. LPA met with staff Alma Payumo and discussed the purpose of the inspection. During the inspection LPA Gutierrez and staff Payumo conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

This is a single-story house with three bedrooms, and two bathrooms. During the inspection LPA observed two staff and three residents in care. Residents were observed all watching a movie in the living room. LPA inspected common areas, resident rooms, kitchen, and garage and observed no deficiencies. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

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: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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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