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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606024
Report Date: 09/12/2022
Date Signed: 09/12/2022 12:39:25 PM


Document Has Been Signed on 09/12/2022 12:39 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:MAUREEN GUEST HOMEFACILITY NUMBER:
300606024
ADMINISTRATOR:MCKENZIE, VICTORFACILITY TYPE:
740
ADDRESS:9362 MAUREENTELEPHONE:
(714) 539-0391
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 4DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Victor Mckenzie- Administrator TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Andrea Mendivil and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted and granted entry into facility by Administrator Victor Mckenzie and explained the reason for the visit.

At 11:22 AM, LPAs toured facility with Administrator Victor Mckenzie. Facility has 4 residents present during today’s visit. Facility is a 4 bedroom, 2 bathroom, single story home with an attached garage. LPAs observed a screening and sanitizing station at entrance of the facility. LPAs observed residents relaxing in the facility. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Facility has 2 refrigerators with ample food supply. LPAs observed facility has emergency food and water supply. LPAs observed unsecured medicine cabinet located in living room. LPAs observed unsecured cleaning supplies underneath kitchen sink. LPAs toured the outside grounds and observed outside visitation area. Exit gates are unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. . LPAs reviewed all residents’ files and all contained required documentation including updated emergency information. All staff and residents are fully vaccinated for Covid 19.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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 2


Document Has Been Signed on 09/12/2022 12:39 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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPAs observed unsecured medicine cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee corrected during visit.
Type A
Section Cited
CCR
87705(f)(2)
UNSECURE TOXINS
The following shall be stored inacessible to residents with Dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPAs observed unsecured cleaning supplies under kitchen sink which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee corrected during visit.

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) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2