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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000924
Report Date: 02/06/2024
Date Signed: 02/06/2024 05:05:22 PM

Document Has Been Signed on 02/06/2024 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
ORANGE COUNTY RO, 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:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Evangeline Bruno TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Evangeline Bruno and explained the reason for the visit. Administrator's certificate expires on 8/27/2024. LPA and Administrator toured the facility. Facility has 4 bedrooms, living room with screened fireplace, family room with a screened fireplace, eat in kitchen 2 bathrooms and a detached two car garage that is used for storage. Smoke detectors and carbon monoxide detectors tested operational. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed all resident bedrooms were clean and organized. All bedrooms had the required furnishings. Both bathrooms were clean and operational. Hot water measured 114.8 degrees Fahrenheit in both bathrooms. LPA observed a 2 day perishable food supply and a 7 day non-perishable food supply in the kitchen. LPA observed the knives are kept locked under the kitchen sink. LPA observed the cleaning supplies are kept locked in the laundry closet. LPA and Administrator toured the backyard. No bodies of water observed. The exit gate is operational. The patio is covered and there are two separate seating areas. No obstacles or hazards observed in the backyard. No obstacles or hazards observed inside of the facility. LPA and Administrator toured the garage. LPA observed tools and supplies throughout the garage. The garage is kept locked and off limits to residents. LPA observed most of the items are kept on the floor in the garage. LPA inspected the all of the resident's medication, no discrepancies observed. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA reviewed 2 out of 2 staff files. No discrepancies observed. LPA reviewed 6 out of 6 resident files, no discrepancies observed. LPA interviewed staff and residents. 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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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