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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002871
Report Date: 07/06/2021
Date Signed: 07/07/2021 09:06:21 AM

Document Has Been Signed on 07/07/2021 09:06 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:CONCORDIA GUEST HOME - 3FACILITY NUMBER:
306002871
ADMINISTRATOR:CONCORDIA P. VELASCOFACILITY TYPE:
740
ADDRESS:1065 SAN ANTONIO AVENUETELEPHONE:
(714) 990-5952
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 4CENSUS: 2DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Concordia VelascoTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required/Annual visit. LPA Martinez was greeted and granted entry into the facility by Caregiver Orlando De Los Angeles. Administrator Concordia Velasco arrived shortly after and reason for visit was explained..

At 2:15 PM, LPA Martinez toured the facility with Administrator Velasco. Facility has 2 residents in care during today's visit. LPA Martinez observed residents asleep in their room. Both residents appeared to be well taken care of. LPA Martinez met with one resident's family member and stated she was very happy with the care her family was receiving. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPA observed the screening/sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet as well as checking temperature upon entry . Facility takes resident temperatures daily and documents. Facility has COVID-19 precaution postings as well as all required Department postings. LPA Martinez reviewed the Mitigation Plan as well as the facility's COVID-19 prevention plan. LPA observed ample emergency food and water as well as First Aid kit. LPA observed a shaded outside visitation area. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. Facility rooms are currently single occupancy.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2021
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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