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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004780
Report Date:
12/28/2021
Date Signed:
12/29/2021 05:34:34 PM
Document Has Been Signed on
12/29/2021 05:34 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:
AMERIDGE RESIDENTIAL CARE
FACILITY NUMBER:
306004780
ADMINISTRATOR:
ANGELO BUENAVENTURA
FACILITY TYPE:
740
ADDRESS:
620 E. FERN DRIVE
TELEPHONE:
(714) 932-9276
CITY:
FULLERTON
STATE:
CA
ZIP CODE:
92831
CAPACITY:
6
CENSUS:
4
DATE:
12/28/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:05 AM
MET WITH:
Caregiver Nero Kaw
TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Nero Kaw and explained the reason for the visit.
LPA Frank 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 residents temperatures 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 LIC 808 Mitigation Plan.
No citations noted during today's visit. Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME
:
Marina Stanic
LICENSING EVALUATOR NAME
:
Shobhana Frank
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/28/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2021
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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