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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612904
Report Date: 08/01/2024
Date Signed: 08/01/2024 09:36:55 AM

Document Has Been Signed on 08/01/2024 09:36 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: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: 4DATE:
08/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Ariel SantosTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240617115325. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA interviewed residents regarding the complaint allegation. While all residents and staff denied any physical abuse occurring at the facility, three out of three residents interviewed stated Staff 1 yells at residents and speaks inappropriately. Staff 1 indicates a loud voice sometimes when speaking with residents but not meaning any harm.





Based on the observations made during the complaint investigation, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 08/01/2024 09:36 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 08/01/2024 at 08:58 AM
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: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2024
Section Cited
CCR
87468.1(a)(1)

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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded dignity in their personal relationships with staff, residents, and other persons. This req is not being met as evidenced by:
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Licensee to re-train staff on personal rights and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure residents are afforded dignity in the facility. Three out of three residents state S1 yells or speaks inappropriately. This poses 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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


LIC809 (FAS) - (06/04)
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