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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608971
Report Date: 06/09/2021
Date Signed: 06/21/2021 04:29:08 PM

Document Has Been Signed on 06/21/2021 04:29 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDEN GROVE VILLAFACILITY NUMBER:
197608971
ADMINISTRATOR:MORALES, NEIL M.FACILITY TYPE:
740
ADDRESS:8051 GARDEN GROVE AVENUETELEPHONE:
(818) 514-6274
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Neil Morales/ AdministratorTIME COMPLETED:
12:00 PM
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LPA Shanahan and Ruiz along with LPM Gillyard conducted an infection control visit with Administrator Neil Morales. Upon arriving at the front door at 9:30 am LPA was greeted by facility staff and administrator arrived shortly after. LPA observed the COVID 19 signs on the front door and immediately upon entry. LPA’s temperature was not taken and screening questions were not asked by staff and LPA's had to remind staff to follow their mitigation protocols. The facility thermometer was not working properly. LPA confirmed there are five residents at the facility.

LPA's and LPM toured the kitchen briefly while waiting for the administrator. Once the administrator arrived, LPA's and LPM were able to tour the rest of the home. While touring the restroom it was observed to have trash cans with out lids at 09:50am. At 10:05 peeling paint was observed in the hallway next to the bathroom. All batteries in the auditory system need to be replaced so that they can be heard and functional. The screen door on the sliding door needs to be replaced and the screen for the window next to the front door needs to be replaced.

The water temperature was tested and was observed to be 116.8 degrees. LPA requested copies of the LIC 500, LIC 308 and a Franchise Tax Board clearance documentation.

Exit interview conducted and report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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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