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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006502
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:58:46 PM

Document Has Been Signed on 04/30/2024 02:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CALLE DEL CID GUEST HOMEFACILITY NUMBER:
306006502
ADMINISTRATOR/
DIRECTOR:		CELIS, PRISCILLAFACILITY TYPE:
740
ADDRESS:27281 CALLE DEL CIDTELEPHONE:
(949) 573-6489
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
04/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Priscilla Celis, Liza Dela CruzTIME VISIT/
INSPECTION COMPLETED:
03:07 PM
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Licensing Program Analyst (LPA) Joseph Alejandre conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicants Priscilla Celis, Liza Dela Cruz and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on January 29, 2024. The facility is to have a capacity of 6, of which 6 can be nonambulatory and 0 bedridden. Applicant has requested a hospice waiver for 6 residents. Facility phone number 949-215-1591. LPA observed the following.

Structure:
The facility is a one story house with an attached 2 car garage with 5 bedrooms, 3 bathrooms, kitchen, dining room, living room and a family room with a screened fireplace. There are 8 exits, one exit door in the family room, one exit door in the garage, a sliding door in the dining room, a sliding door in the living room, the front door, bedrooms 4 has an exit door, bedrooms 1 and 5 have sliding exit doors.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Resident Bedrooms:
There are 5 Resident Bedrooms. Bedroom 5 is shared. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings.

Bedrooms Staff:
There are no staff bedrooms.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CALLE DEL CID GUEST HOME
FACILITY NUMBER: 306006502
VISIT DATE: 04/30/2024
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Bathrooms:
All bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hallway linen closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review, an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week.

Food Service:
There are no residents living in the facility at this time. There is 7-day non-perishable food supply on hand.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide detectors are hardwired and tested operational. The fire extinguisher mounted on the wall in the kitchen is fully charged.

Appliances:
There is one 5 gas burner stove which lights unassisted, 1 oven, microwave oven, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All cleaning supplies and chemicals are kept locked in the garage..

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 119.2 to 120.0 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CALLE DEL CID GUEST HOME
FACILITY NUMBER: 306006502
VISIT DATE: 04/30/2024
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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in closet in the hallway. The medication will also be kept secured in the hall closet which is kept locked. The first aid kit has all the required elements.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in the hall cabinet.

Reading Material, Games, Equipment & Materials:
Reading material and games are stored in the living room. There is a large screen TV mounted in the living room.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Ryan Ferdig on March 11, 2024.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Applicant was reminded that it is required to notify LPA when admitting their first resident. This notification may be done by phone, email or fax.

The facility is ready to be licensed. LPA will submit notification to CAB (Central Applications Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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