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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593155
Report Date: 03/17/2025
Date Signed: 03/17/2025 03:14:18 PM

Document Has Been Signed on 03/17/2025 03:14 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LISA MARIE GUEST HOMEFACILITY NUMBER:
191593155
ADMINISTRATOR/
DIRECTOR:		OTERO, IMELDAFACILITY TYPE:
735
ADDRESS:3451 SANTA ANA ST.TELEPHONE:
(323) 587-8726
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY: 6CENSUS: 5DATE:
03/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Robert Otero ManagerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Robert Otero Manager and explained the reason for the visit. The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Robert Otero Manager today 03/17/2025 at 1:25 PM and the following was observed:
Facility contains 6 Client Bedrooms and 2 Client Bathrooms, dining room, living room, TV room, and activity room.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.
Interviews were conducted with 2 clients with 3 client's unable to be interviewed. (sleeping) and 1 staff (only staff on duty.). 5 client files and 1 staff file were reviewed
All staff were cleared and associated.
Medication was administered per physician's directions.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
1 Staff responsible for providing care and supervision did not have current training in First Aid.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition.
1 Staff responsible for providing care and supervision did not have current training in First Aid.
Deficiency cited on 809 D.
Exit interview conducted
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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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Document Has Been Signed on 03/17/2025 03:14 PM - It Cannot Be Edited


Created By: Glenn Trueman On 03/17/2025 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LISA MARIE GUEST HOME
FACILITY NUMBER: 191593155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in [1] out of 1] staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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Facility to submit current First Aid by for 1 staff by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
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