306003585-12-14-2021-22-AS-RMAZ-C9PNLQ-20211214093355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003585
Report Date: 12/14/2021
Date Signed: 12/14/2021 09:34:02 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/14/2021 09:34 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:	CALIFORNIA GUEST HOME II		FACILITY NUMBER:	306003585
ADMINISTRATOR:	LUMING GUSTAVE		FACILITY TYPE:	740
ADDRESS:	1150 N. HARDING STREET		TELEPHONE:	(714) 923-4692
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY: 6		CENSUS: 0	DATE:	12/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Luming Gustave, Administrator		TIME COMPLETED:	09:40 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Ruth Martinez and Kevin Saborit-Guasch is conducting this unannounced visit for the purpose of completing an annual inspection. LPAs arrived at facility was greeted and granted entry by Administrator. During today’s visit LPAs met with Luming Gustave, Administrator and explained the nature if the visit. LPAs toured the facility and inspected the physical plant, no residents were observed at the facility. LPA was informed that there are no residents currently residing at the facility and only occupant is Administrators. LPA was informed that facility last had residents in January of 2019 and resident was moved to one of their other facilities since. Licensee will contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents of if there are any changes with the license. LPA was informed that Administrator just paid the annual fee for the license. The facility has completed the LIC808 Mitigation Plan, the plan was approved by the Department on March 05, 2021.

At this time there were no deficiencies to report in the facility. As noted above, Licensee will contact CCLD once residents are being admitted. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following:

- An updated Personnel Report (LIC 500).

- Copy of Administrator Certificate.

This report was reviewed with administrator and a copy of this LIC809 report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

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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