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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000332
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:05:43 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/29/2022 11:05 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:PILGRIM'S FAITH CARE HOMEFACILITY NUMBER:
306000332
ADMINISTRATOR:VIVIAN JONAH S. RUEDASFACILITY TYPE:
740
ADDRESS:8380 MONTANA AVENUETELEPHONE:
(714) 562-0190
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 5DATE:
04/29/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Vivien Ruedas, AdministratorTIME COMPLETED:
11:20 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a case management visit following up on the required annual visit conducted on 04/22/2022. LPA arrived at facility, was greeted and granted entry by administrator Vivien Ruedas after explaining the purpose of the visit.

At approximately 11:00am, LPA accompanied by administrator toured the inside and outside of the facility. A Technical Violation issued on 04/22/2022 indicated that the following items had to be tended to "Medication pillboxes as well as all pre-poured medication have to be under lock until ready to administer, Cleaning products should be put away immediately after use, Laundry detergents has to be returned to the cabinet when not in immediate use and The drawer for sharp instruments needs to be locked back right after use". LPA was able to observe that the above items are currently in compliance.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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