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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005478
Report Date: 03/14/2023
Date Signed: 03/14/2023 01:25:29 PM

Document Has Been Signed on 03/14/2023 01:25 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:SAINT BENEDICT CARE LLCFACILITY NUMBER:
306005478
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:8925 CANARY AVENUETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
03/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Kristine Guevarra, Lead Caregiver TIME COMPLETED:
01:25 PM
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On today's date, Licensing Program Analyst (LPA) LPA Quiroz was COVID-19 screened and greeted by Lead Caregiver (LCG) Kristine Guevarra. LPA Quiroz called (L/AD) Almiranez upon arrival to the facility and left voicemail discussing purpose of today's unannounced visit.

LPA Quiroz met with (LCG) and discussed purpose of today's unannounced visit to conduct a case management-other inspection visit to address changes of amended report for complaint control #22-AS-20221114115222 conducted on 2/1/2023 . LPA Quiroz reviewed changes of report with (LCG) Guevarra and indicated that Unfounded findings would remain the same as original report dated 2/1/2023.

During today’s visit, LPA Quiroz along with (LCG) Kristine Guevarra conducted a facility tour inspection of facility premises.

No deficiencies noted during today's visit. An exit interview was conducted with (LCG) Guevarra, and a copy of this report along with Copy of Amended Report for complaint control # 22-AS-20221114115222 were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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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