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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300603359
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:22:37 PM


Document Has Been Signed on 03/19/2024 01:22 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GOLDEN YEARS GUEST HOME THEFACILITY NUMBER:
300603359
ADMINISTRATOR:KRISTINE R LINARESFACILITY TYPE:
740
ADDRESS:14752 HOLT AVETELEPHONE:
(714) 731-6385
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:0CENSUS: DATE:
03/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an attempted unannounced visit via telephone to deliver findings on an investigation completed by the Department. LPA was unsuccessful contacting the Licensee. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency.

Resident 1 (R1) was admitted to the facility on July 14, 2023, and has a diagnosis of Dementia per Physician report dated July 14, 2023.

On August 15, 2024, at around 7 AM, R1 was found by Staff 1 (S1) slipping through their bedrail, with half their torso slipping down and their arms embracing the railing. Staff 2 (S2) who was on duty during the night reported checking on R1 around 4 AM and observing them sleeping soundly. An X-Ray was ordered by R1’s Hospice Doctor which confirmed R1 had an acute non displaced interarticular mid olecranon fracture due to fall. The facility is licensed for a total capacity of 15 of which are to be spread out over the two homes on the property. Per interviews conducted with caregivers, there is only one staff on duty during the hours of 1900 to 0700 hours for both houses on the property. The night of R1’s slip, S2 reported leaving the house in which R1 resides and going to the other house at around 5AM. Interviews with residents confirmed the facility has a call pendant to call caregivers for assistance; however, R1’s physician report indicates R1 is unable to communicate needs. Interviews with the facility house manager confirmed they did not think R1 would’ve been able to use the call pendant as R1 was not mentally capable of taking care or comprehending.

Interviews with the house manager reported R1’s spouse was in charge of giving R1 their medications and would often tell staff they would not give R1 their full medications in hopes it would help their condition. The facility Medication Administration Record (MAR) for R1 notes Staff 3 (S3) administered R1’s medications on August 14, 2023, however, S3 reported they were off and were in Las Vegas at the time. S3 reported they pre-pour resident’s medications for the week and R1’s spouse Administers R1’s medications. Per review of facility records, as of November 09, 2023, Administrator Arlene Mahinay and House Manager did not have their fingerprints associated to facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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 4


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: GOLDEN YEARS GUEST HOME THE
FACILITY NUMBER: 300603359
VISIT DATE: 03/19/2024
NARRATIVE
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Furthermore, S2 failed to have an active background check clearance.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

The facility has been closed effective December 19, 2023. Attempts to reach Licensee to conduct an exit interview were unsuccessful. A copy of this report, 9099-D Page and appeal rights will be certified mailed to the Licensee’s last known address.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/19/2024 01:22 PM - It Cannot Be Edited

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: GOLDEN YEARS GUEST HOME THE
FACILITY NUMBER: 300603359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87705(c)(4)

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87705(c)(4) Care of Persons with Dementia- There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by:
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Facility has closed and Licensee has ceased all operation.
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 Licensee failed to ensure there was an adequate number of direct care staff to meet R1’s needs as evidence by one care staff on duty during the hours of 1900 and 0700 over the span of two houses. Per R1’s physician report, R1 requires 24/7 Care and supervision. This poses an immediate health and safety risk to residents in care.
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Type A
03/15/2024
Section Cited
CCR87465(a)(4)

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 The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:
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Facility has closed and Licensee has ceased all operation.
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Licensee failed to assist R1 with medication administration. Staff relied on R1’s spouse to administer R1’s medications. House manager acknowledged knowing R1’s spouse was not administering medications as prescribed. This poses an immediate health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/19/2024 01:22 PM - It Cannot Be Edited

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: GOLDEN YEARS GUEST HOME THE
FACILITY NUMBER: 300603359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87465(c)(3)

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A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response… This requirement was not met as evidence by:
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Facility has closed and Licensee has ceased all operation.
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Based on record review, Licensee failed to ensure an accurate record of medications administered was maintained for R1 was record notates that medications for R1 was Administered on 8/14/23 by S3 who was off the day in question. This poses a potential health and safety risk to residents in care.
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Type A
03/15/2024
Section Cited
CCR87411(g)

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 Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Obtain a California clearance…Request a transfer of a criminal record clearance… This requirement was not met as evidence by:
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Facility has closed and Licensee has ceased all operation.
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Based on record review, Licensee failed to ensure Administrator and House Manager’s criminal record clearance was transferred and Staff 2 obtained a clearance. This poses an immediate health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4