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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602639
Report Date: 03/04/2022
Date Signed: 03/04/2022 05:05:40 PM

Document Has Been Signed on 03/04/2022 05:05 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PRINCESS BOARD & CARE CORP.FACILITY NUMBER:
374602639
ADMINISTRATOR:GUMABON, REMEDOR C.FACILITY TYPE:
735
ADDRESS:1203 EAST 1ST STREETTELEPHONE:
(619) 434-7343
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 6CENSUS: 4DATE:
03/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Administrator, Remedor GumabonTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Marisela Garcia- Ceteno conducted a Case Management visit regarding a decrease in capacity application. LPA identified herself to Caregiver, Miriam Montano and discussed the purpose of the visit with Administrator, Remedor Gumabon.

Licensee applied for a decrease in capacity from six (6) ambulatory residents to four (4) nonambulatory residents. There is an approved Fire Clearance dated 2-8-2022 for the decrease in capacity and nonambulatory status. As of today, there are four (4) residents in care. LPA toured the facility and a had a discussion with the Administrator regarding operation.

During the tour, LPA observed the physical plant and residents' accommodations including furnishings, linens and personal hygiene items; resident bathrooms are equipped with cleaning products and paper towels; toxic substances are stored in a locked cabinet in the garage and in the kitchen; medication storage and administration logs are located in a locked cabinet; sufficient space to conduct activities was present; facility posting requirements were present in a common area; the facility administrators certification was current; no pool or other body of water is present on the facility grounds; per the Administrator there are no guns, weapons or ammunition located on the property. Discussed with Administrator Gumabon, continuing operation requirements, record keeping and physical plant compliance.

No deficiencies were issued during this visit.

An exit interview was conducted with Administrator, Remedor Gumabon , and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic read receipt confirmation was requested to be sent by Administrator, Gumabon upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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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