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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000924
Report Date: 02/22/2022
Date Signed: 02/22/2022 12:51:14 PM

Document Has Been Signed on 02/22/2022 12:51 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:QUEEN MARY GUEST HOMEFACILITY NUMBER:
306000924
ADMINISTRATOR:EVANGELINE BRUNOFACILITY TYPE:
740
ADDRESS:442 N. SYRACUSE ST.TELEPHONE:
(714) 952-2269
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Evangeline Bruno TIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA observed the See Something Say Something poster (PUB 475) was 81/2" X 11" inches. LPA observed Covid-19 precautionary signs posted on the front door and entrance way. The Administrator Evangeline Bruno arrived at 11:30 am. LPA and Administrator toured the facility. Facility is a 5 bedroom (1 bedroom is for caregivers), 2 bathroom house with an eat in kitchen, living room, family room and a detached two car garage. Both the family room and living room have a fireplace. Both fireplaces are screened. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand. The kitchen is clean and the stove is operational. LPA inspected the first aid. The first aid kit has all the required elements. LPA observed the medication is kept locked in a kitchen cabinet. LPA observed knives are kept locked under the sink. Smoke detectors/carbon monoxide detectors tested operational. Both bathrooms were clean and operational. Hot water measured 119.0 degrees Fahrenheit in bathroom 1 and 114.0 degrees Fahrenheit in bathroom 2. LPA observed all resident rooms had the required furnishings. LPA and Administrator toured the garage. The garage is kept locked and used for storage. LPA and Administrator toured the backyard. The backyard has a covered patio with a seating area with a table and chairs. Both side exit gates are operational. LPA observed on the South side of the house close to the exit gate there were ladders and boxes. Facility has a mitigation plan that is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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