<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003507
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:23:34 AM

Document Has Been Signed on 06/14/2024 11:23 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/
DIRECTOR:
ADELINE V. MONCERAFACILITY TYPE:
740
ADDRESS:2108 CARLETON CIRCLETELEPHONE:
(714) 504-0697
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 2DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:Adeline MonceraTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Adeline Moncera and explained the purpose of the inspection.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a two-story home with two resident bedrooms, one staff bedroom, two bathrooms, and attached two-car garage on the first floor. The second story is used solely as staff quarters. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed one resident present, watching television in the living room, second facility resident was away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 118.9 degrees Fahrenheit. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher service tag indicated it was last serviced on January 28, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps, all and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked. LPA reviewed two out of two resident files and two staff files. LPA interviewed staff and resident present.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1