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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
300606285
Report Date:
12/31/2024
Date Signed:
12/31/2024 01:23:43 PM
Document Has Been Signed on
12/31/2024 01:23 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:
CENTURY GUEST HOME, THE
FACILITY NUMBER:
300606285
ADMINISTRATOR/
DIRECTOR:
LIEZL DEOCAMPO
FACILITY TYPE:
740
ADDRESS:
14332 HOLT AVE
TELEPHONE:
(714) 544-7909
CITY:
SANTA ANA
STATE:
CA
ZIP CODE:
92705
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
4
DATE:
12/31/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:
Gabriela Ramos, facility staff
Liezl Deocampo, administrator
TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving after introducing himself and stating the purpose of the visit. Facility administrator Liezl Deocampo was notified by telephone and could not physically be present.
There are currently four residents in care, two of which are receiving hospice care. Facility hospice waiver capacity is for one resident only. Citation issued. LPA observed residents relaxing in the facility’s common area or in their respective bedrooms. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has four bedrooms with two bathroom for residents Additional staff dwelling are located in the house as well as in an Additional Dwelling Unit which is not accessible to residents. Bedrooms appeared clean and sanitary. Full bed rails present in three bedrooms, orders reviewed. LPA observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and slip mats. Hot water temperature measured at 117F.
LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. LPA observed two knives locked in an unsecure drawer while the others are in the locked cabinet. Citation issued. A fire extinguisher is verified to be charged and mounted to the wall. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked cabinet in the hallway. The attached garage is inaccessible to residents and is used for storage. Cleaning supplies are stored partially under the unsecure kitchen sink and in the secure cabinet. Citation issued.
CONTINUED ON FORM LIC809-C
Sheila Santos
TELEPHONE:
(714) 334-2062
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
DATE:
12/31/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
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
13
Document Has Been Signed on
12/31/2024 01:23 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:
CENTURY GUEST HOME, THE
FACILITY NUMBER:
300606285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as one resident is assessed to be bedridden while the fire clearance does not include any such provisions. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/01/2025
Plan of Correction
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Licensee to submit an updated LIC200 and facility sketch in order to request an update to the fire clearance including at least one bedridden room.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
TELEPHONE:
(714) 334-2062
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
DATE:
12/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
LIC809
(FAS) - (06/04)
Page:
2
of
13
Document Has Been Signed on
12/31/2024 01:23 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:
CENTURY GUEST HOME, THE
FACILITY NUMBER:
300606285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and staff interview, the licensee did not comply with the section cited above as some cleaning supplies are stored unsecurely in a kitchen cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
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Licensee will either ensure all cleaning supplies are located in the secure cabinet or install a lock on the kitchen cabinet also.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
TELEPHONE:
(714) 334-2062
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
DATE:
12/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
LIC809
(FAS) - (06/04)
Page:
3
of
13
Document Has Been Signed on
12/31/2024 01:23 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:
CENTURY GUEST HOME, THE
FACILITY NUMBER:
300606285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, staff interview and record review, the licensee did not comply with the section cited above as all four residents are receiving hospice care in spite of a hospice waiver capacity of only one which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
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Licensee to submit a request to increase their hospice waiver capacity to Community Care Licensing before the plan of corrections due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
TELEPHONE:
(714) 334-2062
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
DATE:
12/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
LIC809
(FAS) - (06/04)
Page:
4
of
13
Document Has Been Signed on
12/31/2024 01:23 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:
CENTURY GUEST HOME, THE
FACILITY NUMBER:
300606285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) 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 record review, the licensee did not comply with the section cited above as two out of four residents had medical assessments dated from over a year in spite of the presence of a dementia diagnosis. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/31/2025
Plan of Correction
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Licensee to obtain updated physician reports for the residents in question and provide documentation thereof to LPA before the plan of corrections due date.
Section Cited
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and staff interview, the licensee did not comply with the section cited aboveas two knives are kept in an unsecure drawer in the kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/10/2025
Plan of Correction
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2
3
4
Licensee to provide a secure storage solution for sharp items in the kitchen,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
TELEPHONE:
(714) 334-2062
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
DATE:
12/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
LIC809
(FAS) - (06/04)
Page:
5
of
13
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:
CENTURY GUEST HOME, THE
FACILITY NUMBER:
300606285
VISIT DATE:
12/31/2024
NARRATIVE
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CONTINUED FROM FORM LIC809
LPA and facility staff toured the outside of the facility and observed it to be currently inaccessible and under construction. The main route of egress is however unaffected. Consultation provided. LPAs observed an shaded outdoor seating areas with furniture for resident use. The perimeter gates on one side of the property is self-latching and can easily be opened in an evacuation. There is a koi pond which will require to be secure once access to the backyard is restored. Consultation provided.
LPA reviewed four resident records which included all necessary components. Two physician reports for dementia residents are however out of date. LPA reviewed resident medication records. Prescription orders verified for all four residents. LPA reviewed two staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. There is no Infection Control and Emergency and Disaster plans need to be updated. Consultation provided.
Based on the observations made during today’s visit, five deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Multiple consultations provided. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/31/2024
LIC809
(FAS) - (06/04)
Page:
13
of
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