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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006600
Report Date: 10/04/2024
Date Signed: 10/04/2024 10:05:06 AM

Document Has Been Signed on 10/04/2024 10:05 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BRENDA'S GUEST HOMEFACILITY NUMBER:
306006600
ADMINISTRATOR/
DIRECTOR:		AZNAR, BRENDAFACILITY TYPE:
740
ADDRESS:1274 N SIESTA AVETELEPHONE:
(714) 932-4194
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 0DATE:
10/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:04 AM
MET WITH:Administrator, Brenda AznarTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation for change of Location. Facility is a single story residential home. LPA along with Administrator/Licensee Brenda Aznar toured facility at 7:21AM and observed the following:

Fire clearance approval was received on 09/09/2024. Structure: Facility is a one story, 5 bedroom (3 shared Residents bedrooms and 2 live in staff bedrooms), 3 bathroom house with attached garage and a separate Accessory Dwelling Unit (ADU) located in the back yard used for Licensee living corridors . Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Facility has fire place with covered screen. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Facility has working land line telephone. Facility has emergency flashlights as well as night lights located in hallway. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors and carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on sliding/exit doors. Appliances: Gas Stove and refrigerator are operational. Toxins: LPA observed toxins secured in storage area underneath sink Water Temperature: Tested and recorded at 110.1 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has ample supply of puzzles, games, coloring kits and crafts. Medications, First-Aid Kit & Book: Facility has first aid kit and First aid manual present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility as required. LPA observed shaded outdoor seating.

CONTINUED ON 809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BRENDA'S GUEST HOME
FACILITY NUMBER: 306006600
VISIT DATE: 10/04/2024
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Administrator's Certificate observed on wall for Brenda Aznar certificate number 7032568740 expiring October 21,2024.

Component III Orientation was waived during this pre-licensing visit due to Administrator/ licensee presently operating facility and had Component III during initial visit.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Administrator/licensee and a copy of report was left at facility
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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