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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600654
Report Date: 03/10/2023
Date Signed: 05/22/2023 04:00:56 PM

Document Has Been Signed on 05/22/2023 04:00 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:CONTINENTAL GUEST HOMEFACILITY NUMBER:
198600654
ADMINISTRATOR:RUBERTO BALUYOTFACILITY TYPE:
735
ADDRESS:15482 PASTRANA DRIVETELEPHONE:
(714) 522-3013
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 2DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Administrator Gina BaluyotTIME COMPLETED:
02:45 PM
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***This is an Amended report***
Licensing Program Analyst (LPA) Ashley Calderon made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon visit LPA met with DSP worker Edna Calanog. Shortly after LPA met with Administrator Gina Baluyot to discuss the purpose of the visit.

LPA Calderon started the Care Tools with DSP Edna and shortly after Gina assisted with domains.
LPA conducted a tour of the facility along side with Gina. Facility is a one story family home with four (4) bedrooms (1 staff bedroom), two (2) bathrooms (one for staff and one for clients), living room, kitchen, dining area, laundry room, backyard and an attached garage inaccessible to clients.

The following was conducted and inspected:
  • Outdoor and indoor passageways are free of obstruction.
  • Bathrooms were clean and operational with grab bars and non-ski mat, hot water measured at 117.6 F.
  • Smoke detectors were tested. The last fire drill was conducted on 10/24/2022. Done quarterly.
  • Fire alarms are interconnected and operational.
  • Required postings observed.
  • The fire extinguisher is located in the kitchen.
  • Carbon Monoxide detector was located in the living room. It was tested and operable.
  • Sufficient supply of extra linen, towels and personal hygiene supplies. Linens supplies are stored inside the hallway cabinet. Extra Hygiene supplies and PPE are stored inside the garage.
  • Comfortable temperature for clients was maintained, 72 F.
  • Washer/Dryer appliances observed.
Front and back yard is in good condition, shaded area is provided.
(Continuation on 809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CONTINENTAL GUEST HOME
FACILITY NUMBER: 198600654
VISIT DATE: 03/10/2023
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***This is an amended report***
KITCHEN:
  • Freezers/refrigerators appear sanitary and temperature maintained. There is an extra refrigerator located inside the garage.
  • Sufficient non-perishable and perishable food items for clients in care, emergency canned goods stored near kitchen and in garage.
  • Toxins and sharps locked and inaccessible to clients.

BEDROOMS:
  • Bedrooms #1-#3 had required furnishing. Bedroom#4 is for live in staff.
  • Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads.

MEDICATION:
  • Medications are stored, locked and inaccessible to clients, located in cabinet in the hallway.
  • Medication and First Aid Kit reviewed.
  • LPA reviewed (4) resident medication and discovered Client #1's medication Divalprox Sodium Delayed Release not given according to the physician's directions.

RECORD REVIEW:
At approximately 11 A.M, LPA reviewed Staff and Client files. As a part of the inspection reviewed (4) resident records, (3) staff files. Currently the facility has (4) clients which (2) are ambulatory and (2) is non-ambulatory.
  • Facility Administrator Certificate for Gina Baluyot expires on 12/18/23 / Administrator Certificate for Ruperto Baluyot expires on 9/14/2023.
  • Staff (files reviewed) have current First Aid/CPR Certificates.
  • Staff (files reviewed) have Criminal Clearances on file.

Care Tool was completed and based on Title 22 Regulations Deficiencies will be documented on LIC 809D. No civil penalties were issued.

An exit interview was conducted with Administrator Gina Baluyot and a copy of today's reports / appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2023 04:01 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/22/2023 11:53 AM


Created By: Ashley Calderon On 03/10/2023 at 02:05 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CONTINENTAL GUEST HOME
FACILITY NUMBER: 198600654

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
80076(b)(5)(B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the Staff / Licensee/ Administrator did not comply with the section cited above. One client in care, medication was not provided to client based on physician's directions which poses an immediate health, safety or personal rights risk to person(s) in care.
POC Due Date: 03/11/2023
Plan of Correction
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Administrator will immediately provide Client with appropriate medication needed. Administrator will contact client's Physician on instructions for missed medication and will provide LPA with document regarding a in-service training with staff who administer medication, will review Title 22 Regulation on Health Related Services, review how to follow medication labels, and how to review/ organize Medication Log. No civil penalties were issued.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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