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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606285
Report Date: 11/03/2022
Date Signed: 11/03/2022 10:42:50 AM


Document Has Been Signed on 11/03/2022 10:42 AM - 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:CENTURY GUEST HOME, THEFACILITY NUMBER:
300606285
ADMINISTRATOR:LIEZL DEOCAMPOFACILITY TYPE:
740
ADDRESS:14332 HOLT AVETELEPHONE:
(714) 544-7909
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Liezl DeOcampoTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Administrator Liezl DeOcampo and stated the purpose of this visit.

The facility is a single-level structure and licensed for six non-ambulatory with a hospice waiver for one. This facility is a Residential Care Facility for the Elderly/Dementia.

At about 9:26 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 residents in care and Administrator on duty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms and 2 staff rooms. Residents do not have access to staff rooms and area which include the garage. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathroom was observed to be in good repair and provided with grab bars and hot water was measured at 112.4 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Facility offers a 3-car garage with an operational washer/dryer, additional refrigerators and freezers.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285
VISIT DATE: 11/03/2022
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For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. The backyard also provides a path to Administrator’s home. The backyard contained several plants in good repair.

LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster Plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Administrator Liezl DeOcampo and a copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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