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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004312
Report Date: 06/02/2021
Date Signed: 06/02/2021 03:09:27 PM

Document Has Been Signed on 06/02/2021 03:09 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:PRECIOUS HOME CARE IIFACILITY NUMBER:
306004312
ADMINISTRATOR:GRACE RADFORDFACILITY TYPE:
740
ADDRESS:24531 VANESSA DRIVETELEPHONE:
(949) 215-3090
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
06/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Administrator Grace RadfordTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management for a written report that Administrator (AD) Grace Radford provided. LPA met with AD G. Radford and stated the purpose of the visit.

On May 31, 2021, via email Community Licensing Division received a report on alleged resident's personal right violation in the facility.

For this visit, LPA Marin conducted a tour of the facility with AD G. Radford. LPA interviewed staff members and resident. After the interview, LPA reviewed facility files with included but no limited to preadmission appraisal, needs and services plan, physician's report, and staff records and training. LPA discussed with AD the California Code of Regulations (CCR) Section 87211. LPA also discussed with AD the features of the Guardian system. AD discussed the infection control procedure of the facility to the LPA.

For this visit, no deficiency was observed. No citation was issued.

LPA Marin conducted an exit interview with AD G. Radford. Copies of this report and CCR discussed were left at the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2021
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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