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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612904
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:10:20 PM

Document Has Been Signed on 12/06/2024 05:10 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:ADELINE GUEST HOMEFACILITY NUMBER:
300612904
ADMINISTRATOR/
DIRECTOR:		ADELINA MONCERAFACILITY TYPE:
740
ADDRESS:741 N. EAST STREETTELEPHONE:
(714) 996-0568
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 3DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ariel Santos, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nancy Guillen and Claudia Gutierrez conducted this unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and were greeted and granted entry by Staff Ariel Santos. LPAs explained the nature of the visit. Administrator (AD) Adeline Moncera was contacted by phone and provided assistance via phone throughout the duration of the inspection. The facility is licensed for 6 bedridden and has a hospice waiver for 2 residents. The facility currently has three residents, two of which are on hospice.

During the inspection, LPAs and Staff Santos conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with four resident bedrooms, two bathrooms, and attached two-car garage. In the garage, LPAs observed a bed and staff's personal belongings, including clothing, shoes, and toiletries and staff indicated they occasionally sleep on-site in the garage; a Deficiency was cited on today’s date. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened. The backyard has a shaded sitting area. LPAs observed residents watching television in their perspective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.2 - 120.7 degrees Fahrenheit.

LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated June 2, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication cabinet was observed to be locked; however, routine medications are prepped 24-hours in advanced and transferred from their original container to a clear plastic cup; a Deficiency was cited on today’s date. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/06/2024 05:10 PM - It Cannot Be Edited


Created By: Nancy Guillen On 12/06/2024 at 04:18 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: ADELINE GUEST HOME
FACILITY NUMBER: 300612904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interview and record review, the licensee did not comply with the section cited above in one of three resident records which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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Staff Santos stated physician written orders for resident will be obtained and maintained on file, and a copy provided to LPA via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/06/2024 05:10 PM - It Cannot Be Edited


Created By: Nancy Guillen On 12/06/2024 at 04:18 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: ADELINE GUEST HOME
FACILITY NUMBER: 300612904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 AD was unable to provide a copy of current, unexpired liability insurance which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Staff Santos stated a copy of current, unexpired liability insurance will be provided to LPA via email by POC date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above in three of three resident medications which poses a potential health and safety risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Staff Santos stated medication will no longer be transferred between containers, staff training will be conducted regarding proper storage of medication and proof provided to LPA via email.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/06/2024 05:10 PM - It Cannot Be Edited


Created By: Nancy Guillen On 12/06/2024 at 04:39 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: ADELINE GUEST HOME
FACILITY NUMBER: 300612904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accomodations and privacy for the residents, staff, and others who may reside in the facility...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as a bed and staff's personal belongings were observed in the garage and staff indicated staff they sleep onsite in the garage, which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Staff Santos stated the bed and staff's personal belongings will be removed and staff will no longer sleep in the garage and picture proof provided to LPA via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: ADELINE GUEST HOME
FACILITY NUMBER: 300612904
VISIT DATE: 12/06/2024
NARRATIVE
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LPAs conducted medication and centrally stored medication records review and observed one out of three residents did not have any physician orders for their medication and staff were unable to provide LPAs with a copy for resident’s physician orders; a Deficiency was cited on this date. LPAs reviewed three of three resident files and two staff files. LPAs interviewed three residents and staff.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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