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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004327
Report Date: 10/04/2021
Date Signed: 10/04/2021 02:48:59 PM

Document Has Been Signed on 10/04/2021 02:48 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:AINA'S GUEST HOMESFACILITY NUMBER:
306004327
ADMINISTRATOR:ANGELO BUENAVENTURAFACILITY TYPE:
740
ADDRESS:16211 TUNISIA CIRCLETELEPHONE:
(714) 854-7868
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 4DATE:
10/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Charlida Aliola TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA informed Staff (S1) of the purpose of the visit and was granted entry into the facility. LPA met with S1 and discussed the purpose of the inspection. During the inspection, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA observed the following:

There were 2 staff and 4 residents present at the facility. Resident rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed hallways and walkways that were free of obstruction. LPA provided technical assistance regarding temperature checks, documentation, and Covid-19 facemask requirements. LPA and S1 discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19).

No deficiencies were noted during the inspection.

An exit interview was conducted with S1 and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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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