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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606024
Report Date: 09/03/2026
Date Signed: 09/03/2026 02:26:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 02:26 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/
DIRECTOR:		MCKENZIE, VICTORFACILITY TYPE:
740
ADDRESS:9362 MAUREENTELEPHONE:
(714) 539-0391
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 6DATE:
09/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Victor McKenzieTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Annual Required inspection of the facility. LPA Tea was greeted and granted entry by Licensee (LE) Victor McKenzie. LPA explained the purpose of the visit. The facility is licensed to serve six (6) non-ambulatory residents and has a hospice waiver for three (3) residents. At the time of the inspection, six (6) residents were in care, of which one (1) was receiving hospice services.

LPA reviewed six (6) resident files and two (2) staff files. During the records review, LPA identified discrepancies and missing or incomplete documentation. LPA observed that some residents had outdated Physician's Reports, and one resident did not have a Physician's Report available in the resident's file. LPA was unable to locate current First Aid/CPR training documentation in the staff files reviewed. LPA had previously verified First Aid/CPR training as part of a prior Plan of Correction; however, the documentation was not available in the staff files at the time of today's inspection. LPA also determined that required annual staff training documentation was incomplete. LE McKenzie stated that annual staff training is currently in progress and has not yet been completed. The facility's most recent documented emergency disaster drill was conducted on February 22, 2026. Administrator (AD) Gabrielle Tedjasukmana has completed the required course work and is currently pending administrator certification.

LPA, accompanied by LE McKenzie, toured the interior and exterior of the facility. The inspection included resident bedrooms and bathrooms, common areas, kitchen and food service areas, medication storage, first aid supplies, and the exterior grounds. During the inspection, LPA tested smoke detectors and carbon monoxide detectors located in resident bedrooms and common areas and observed that multiple devices were not operational at the time of testing.

(Annual report continued on LIC809C)

Lourdes Montoya
Michael Tea
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024
VISIT DATE: 09/03/2026
NARRATIVE
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Resident bedrooms contained the required furniture, bed linens, and adequate closet and drawer space to accommodate residents comfortably. However, LPA observed damage to the walls in a resident bedroom. LE McKenzie was advised that the damaged walls require repair and that the facility is required to maintain the physical plant in a safe and good state of repair.

Resident bathrooms were inspected. LPA observed that a bathroom was not maintained in good repair, as the main bathroom lighting was not functioning properly. LPA also observed cobwebs and a spider in the bathroom. LE was reminded that the facility is required to maintain the premises in a clean, safe, sanitary, and good state of repair and to address conditions that may contribute to the presence of insects or pests. The toilets and water faucets were operational, grab bars were secure, and the shower area was free of visible mold and mildew. The hot water temperature measured approximately 108 degrees Fahrenheit. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked at the time of the inspection.

The first aid kit was inspected and contained necessary supplies, including dressings, bandages, tweezers, a thermometer, and scissors.

LPA inspected the kitchen and food supply. The facility maintained an adequate supply of perishable and nonperishable foods at the time of the inspection. However, during an inspection of the pantry, LPA observed expired canned food stored with the facility's food supply. LPA observed that sharps were secured in a locked kitchen drawer. Toxic substances were also locked and inaccessible to residents in care, including substances stored beneath the kitchen sink and in cabinets near the laundry area. The kitchen fire extinguisher was observed to be fully charged. LPA observed that one stove-top burner was not operational at the time of the inspection.

LPA toured the outside grounds. The facility had adequate outdoor seating and shaded areas available for residents. Exit gates located on both sides of the facility were observed to be self-latching and operational. The facility provides activities based on residents' interests, abilities, and health conditions, including light exercise activities. During the inspection, residents were observed eating lunch and watching television.

LPA reviewed the facility's medication storage and medication administration practices. LPA observed that residents' medications were not maintained in a secured centrally stored location. Some resident medications were also observed to be improperly stored and accessible at the time of the inspection. LPA further

(Annual report continued on LIC809C)

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024
VISIT DATE: 09/03/2026
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observed inconsistencies in the facility's medication documentation and record keeping. Complete and consistent centrally stored medication records were not maintained for medications requiring centralized storage. Based on the records available for review, medications documented as administered were being provided in accordance with physician orders.

LPA interviewed residents regarding the quality of care and services provided by the facility. LPA also interviewed staff present during the inspection regarding resident care and facility operations. At the time of annual visit, residents were seen having lunch and watching television.

Based on observations, interviews, and records reviewed during today's inspection, deficiencies are being cited in accordance with Title 22, Division 6, Chapter 8 of the California Code of Regulations.

Civil penalties are being assessed for repeat deficiencies for which the facility was previously cited and failed to maintain compliance.

An exit interview was conducted with Licensee Victor McKenzie. The deficiencies, Plans of Correction, applicable civil penalties, and appeal rights were reviewed with LE McKenzie. A copy of this report, LIC809-D, LIC9102TV, LIC858, LIC859 civil penalty assessment documentation, and Appeal Rights was provided to the facility at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 02:26 PM - It Cannot Be Edited


Created By: Michael Tea On 09/03/2026 at 12:29 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
HSC
1569.625(b)(2)

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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:
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Facility will complete annual training for staff. Licensee will provide proof to LPA by POC due date.
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Based on LPA's observation, staff annual training was incomplete and pending as licensee is still conducting training. This poses as a potential health and safety risk to residents in care.
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Type B
10/02/2026
Section Cited
HSC1569.311

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Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
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Facility will replace the smoke alarms in resident rooms and provide proof to LPA by POC due date.
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Based on LPA's observation, some resident room's smoke detectors were no longer operational. This poses as a potential 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 02:26 PM - It Cannot Be Edited


Created By: Michael Tea On 09/03/2026 at 12:46 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
CCR
87303(a)

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Maintenance and Operation .. (a)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:
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Facility will repair the wall damages, facility repair bathroom light fixtures, facility will repair stove top burner and provide to LPA by POC due date.
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During the physical plant tour, LPA observed several areas of the facility that were not maintained in good repair. LPA observed damage to the walls in resident bedrooms. In the bathroom, LPA observed cobwebs and the presence of insects, and the main bathroom light was not operational. Additionally, one of the stovetop burners in the did not ignite independently and required the use of an external flame igniter. These conditions pose a potential health and safety risk to residents in care.
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Type B
10/02/2026
Section Cited
CCR87465(h)(6)

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Incidental Medical and Dental Care ... The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
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Facility will created a centrally stored medication list for each resident that lists routine and PRN medication for every month. Creating a new medication list for each month, and keep the old ones for record keeping by POC due date.
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Based on LPA's review of medication records, the facility did not properly maintain accurate and current Centrally Stored Medication and Destruction Records. LPA observed that medication records for some residents were not consistently updated to reflect current medication information. This poses a potential 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 02:26 PM - It Cannot Be Edited


Created By: Michael Tea On 09/03/2026 at 01:00 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
CCR
87458(b)

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Medical Assessment (b) The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by:
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Facility will obtain updated physician's reports for residents and submit proof to LPA by POC due date.
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During LPA's review of resident records, LPA observed that residents' Physician's Reports were not current. Additionally, one resident did not have a current Physician's Report available in their file at the time of the inspection. This poses a potential health and safety risk to residents in care.
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Type B
10/02/2026
Section Cited
CCR87555(b)(8)

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General Food Service Requirements (b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by
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Facility will discard and replace expired canned goods. And submit proof to LPA by POC due date.
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During the inspection of the facility's food supply, LPA observed expired canned food stored in the pantry. This poses a potential 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 02:26 PM - It Cannot Be Edited


Created By: Michael Tea On 09/03/2026 at 01:13 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2026
Section Cited
CCR
87608(a)(3)

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Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
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LPA advised the Licensee that appropriate documentation authorizing the use of bed rails must be maintained in each applicable resident's file and that full-length bed rails are permitted only under applicable hospice requirements. During the visit, the Licensee removed the bed rails from residents who did not have the required authorization or documentation on file.
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During the physical plant tour, LPA observed residents with full-length bed rails. One resident receiving hospice services had documentation authorizing the use of full-length bed rails. However, LPA observed other residents utilizing full-length bed rails without physician's orders supporting their use. The unauthorized use of full-length bed rails poses an immediate health and safety risk to residents in care.
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Type A
09/04/2026
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care Services ... (h) The following requirements shall apply to medications which are centrally stored: (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:
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The Licensee immediately secured the medications in a locked cabinet. LPA reminded the Licensee that all centrally stored medications must be properly secured and inaccessible to residents in care, as required
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Based on LPA's observation the medication was stored in boxes in the living room and not in a locked secured centrally stored location. This poses as 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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