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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006174
Report Date: 08/23/2022
Date Signed: 08/24/2022 09:57:47 AM

Document Has Been Signed on 08/24/2022 09:57 AM - 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:SOPHIA'S GUEST HOMEFACILITY NUMBER:
306006174
ADMINISTRATOR:ESTEBAT, MARLENEFACILITY TYPE:
740
ADDRESS:14891 HOPE ST.TELEPHONE:
(714) 814-3416
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 0DATE:
08/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensure Marlene Estebat TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted announced inspection for the purpose of conducting a pre-licensing inspection and COMP III. LPA met with Licensure Marlene Estebat and discussed the purpose of the inspection. LPA Frank toured the facility along with the Licensure. Application was submitted to Community Care Licensing on 4/1/22.
During the inspection, LPA observed the following.
LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log, COVID posters throughout the facility.

This is a two story home. Facility is a 6 bedroom and 3 bathroom, house with attached garage that is being used for storage. There is a back yard with a patio cover for the residents. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. LPA observe the facility to be clean and in good repair, Physical Plant and Safety of Environment/Operational as CCL Requirements.

Facility telephone number is 657-210-4914 The residents bedrooms are spacious and easily accommodate the residents furnishings. Lamps, chairs, linens, and storage for each residents bedroom. Bathrooms were inspected and observed to be clean, faucets and toilets were operational. Water temperature was tested 107.6 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers 714-814-3416. Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SOPHIA'S GUEST HOME
FACILITY NUMBER: 306006174
VISIT DATE: 08/23/2022
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Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen cabinet. Toxins: observed in the locked cabinet. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Fire clearance was approved by Orange County Fire Authority on 05/31/22.

Licensure was informed that the facility is ready for license and final approval will be processed by the CAU supervisor in Sacramento.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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