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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003847
Report Date:
06/30/2021
Date Signed:
06/30/2021 12:29:43 PM
Document Has Been Signed on
06/30/2021 12:29 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
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
LG GUEST HOME II
FACILITY NUMBER:
306003847
ADMINISTRATOR:
STELLA LADABAN
FACILITY TYPE:
740
ADDRESS:
6700 LASSEN DR.
TELEPHONE:
(714) 484-1493
CITY:
BUENA PARK
STATE:
CA
ZIP CODE:
90620
CAPACITY:
6
CENSUS:
4
DATE:
06/30/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:01 PM
MET WITH:
Stella Ladaban
TIME COMPLETED:
12:38 PM
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Licensing Program Analyst (LPA) Jim August conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Administrator Stella Ladaban and explained the reason for the visit.
LPA August toured the facility. There are four residents residing in the facility and no active covid-19 cases. LPA observed four residents on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking resident temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC808 Mitigation Plan and it has been approved. The facility is still conducting covid-19 testing with all staff as required by the latest guidance. Facility did not have hand washing signs in bathrooms but will put them up today.
No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
James August
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/30/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2021
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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