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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003507
Report Date: 06/29/2021
Date Signed: 07/01/2021 11:06:14 AM

Document Has Been Signed on 07/01/2021 11:06 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:ADELINE'S GUEST HOMEFACILITY NUMBER:
306003507
ADMINISTRATOR:ADELINE V. MONCERAFACILITY TYPE:
740
ADDRESS:2108 CARLETON CIRCLETELEPHONE:
(714) 504-0697
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 2DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Adeline MonceraTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Administrator Adeline Moncera and explained the purpose of the visit.

During the visit LPA toured the facility inside and out with Adeline Moncera. LPA observed Covid signage at front entrance of facility as well as a sanitization station. Facility has required Department postings. LPA observed a copy of Administrator Certificate for Adeline Moncera that expires 6/30/21. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained ample supplies of hand sanitizer, soap, wipes, gloves. LPA observed outside visitation area with ample shading. Residents were observed watching tv in the living room and in their rooms resting. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff at all times.

No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Adeline Moncera.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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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