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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005273
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:28:55 PM

Document Has Been Signed on 11/02/2021 02:28 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:NORA'S RESIDENCE OF PLACENTIAFACILITY NUMBER:
306005273
ADMINISTRATOR:DIMAANO, EUPHROSYNEFACILITY TYPE:
740
ADDRESS:1217 WARREN STREETTELEPHONE:
(714) 310-9495
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Euphrosyne Dimaano TIME COMPLETED:
02:25 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 1 (S1) of the purpose of the visit, completed temperature check, and completed a visitor sign in sheet. LPA and S1 conducted a tour of the inside and outside of the facility, common areas, kitchen, bedrooms, bathrooms, and garage.

LPA discussed and observed the following:

LPA observed Covid-19 station with sign in sheet, hand sanitizer, and disinfectant wipes. The facility also requires temperature checks for all visitors and staff. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed 30-day supply of PPE and hygiene products stored in the garage. Hallways and walkways were free from obstruction. LPA reviewed resident and staff temperature logs which also included symptom questionnaire. LPA met with administrator Euphrosyne Dimaano (AD) and discussed updated Covid-19 requirements including surveillance testing, PPE requirements, and Covid-19 reporting requirements.

No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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