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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611830
Report Date: 07/29/2021
Date Signed: 07/30/2021 09:25:43 AM

Document Has Been Signed on 07/30/2021 09:25 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:CAMBRIDGE HOUSEFACILITY NUMBER:
300611830
ADMINISTRATOR:EVELYN WALLACEFACILITY TYPE:
740
ADDRESS:1895 NORTH CAMBRIDGETELEPHONE:
(714) 637-3911
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 4DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Evelyn WallaceTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Caregiver Irene Shields. Administrator Evelyn Wallace arrived shortly after and the reason for the visit was explained.

Upon entry LPA was was not screened per COVID guidelines. LPA began the tour of the facility. The facility currently has 4 residents in care. LPA observed all 4 residents relaxing, and/or watching TV one resident had a visitor. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff does not screen visitors. LPA observed the screening station in the entrance of the facility with only 2 bottles of hand sanitizer. Facility does not keep documentation in regard to COVID for all the visitors, staff, and resident. LPA observed hand washing guidelines posted in all bathrooms of facility. LPA observed facility has COVID precautionary posting throughout the facility as well as all required Department postings. Facility has an active COVID-19 prevention plan in place for the safety of residents in care. LPA observed ample of emergency food and water as well as First Aid kit in the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place. LPA toured the outside and observed two tables with umbrellas that can be used for outdoor visitation. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation as needed. LPA provided Technical Assistance regarding routine symptom screening (temperature and symptom check), at entry for all staff, residents, and visitors, documenting daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents, and a sign-in policy for all visitors. Mitigation Plan was submitted and has been approved.

Based on the observations made during today’s visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this report, and LIC9102 were provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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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