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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606024
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:06:05 PM


Document Has Been Signed on 09/17/2024 05:06 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
ORANGE COUNTY RO, 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:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Victor McKenzieTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by House Manager (HM), Victor McKenzie and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are four residents, of which one is on hospice during today's visit.

LPA Tea along with the house manager toured the facility at 2:31 PM. LPA toured the physical plant, checked food service, and the first aid kit. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 77.0 F degrees and over 130 F degrees. HM McKenzie was adjusting the boiler, lowering the temperature. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care locked and secured in cabinets by the laundry area. The fire extinguisher in the kitchen is fully charged. The kitchen stove had one working burner at the time of visit. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility is self-latching and operational. LPA observed emergency supplies, food and water supply in a cabinet in the family room. Facility provides activities based on resident interests. At the time of annual visit, residents were seen having snacks and watching television in the family room.



LPA Tea reviewed four resident files and two staff files. There were discrepancies noted in the review of resident and staff files. Administrator (AD) Eduardus Junanto certificate expires on June 05, 2025.

Annual report continued on LIC809C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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Document Has Been Signed on 09/17/2024 05:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation water temperature was too low and too high. This could be a potential health and safety risk to residents in care.
POC Due Date: 10/08/2024
Plan of Correction
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Facility will fix and regulate the water temperature by POC due date, submitting proof to LPA.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of facility records, there is no proof of staff annual staff training in files. This could pose a potential health and safety risk to resident's in care.
POC Due Date: 10/08/2024
Plan of Correction
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Facility/Licensee will provide proof of staff training by POC date 10/08/2024 and submit proof to LPA Tea.
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) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 09/17/2024 05:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of facility records there are no documentation of emergency drills conducted quarterly. This can pose as a potential safety risk to resident's in care.
POC Due Date: 10/08/2024
Plan of Correction
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Facility/Licensee will conduct a diaster drill and document every quarterly and log in a book. Will submit proof to LPA by POC due date 10/08/2024.
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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2024 05:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia ... Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of resident records, one resident who is diagnosed with dementia does not have a current medical assessment, the last medical report was done was in 09/11/2023. Which poses as a potential health and safety risk to residents in care.
POC Due Date: 10/08/2024
Plan of Correction
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Licensee/Facility will obtain a current medical report for resident with dementia and submit proof by POC due date 10/08/2024.
Type B
Section Cited
CCR
87303
Maintenance and Operation ... The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during facility tour the stove had one working burner and required a candle lighter to light up the other stove burners. Also electrical outlet cover in the female resident room needs to be replaced, it is cracked. Also bathroom needs to be cleaned, there is cobwebs and dust in the corners of the ceiling. This could be a potential health and safety risk to residents in care.
POC Due Date: 10/08/2024
Plan of Correction
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Facility/Licensee will repair and clean up the areas mentioned in the deficiencies by POC due date 10/08/24 and submit proof to LPA.
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) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 09/17/2024 05:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services ... All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during facility tour, there are alot of supplies, boxes in the hallway, obstructing the walkway. This could pose as a potential safety risk for residents in care.
POC Due Date: 10/08/2024
Plan of Correction
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Licensee/Facility will clear hallway and put away supplies to prevent tripping hazard and obstruction for the safety of residents by POC due date 10/08/24 and will submit proof to LPA.
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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024
VISIT DATE: 09/17/2024
NARRATIVE
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LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with House Manager, Victor McKenzie and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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