<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613018
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:49:21 PM

Document Has Been Signed on 12/18/2024 03:49 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:DISTOR'S RESIDENTIAL CARE IIFACILITY NUMBER:
300613018
ADMINISTRATOR/
DIRECTOR:		LORI COOKFACILITY TYPE:
735
ADDRESS:23456 WHITE DOVETELEPHONE:
(949) 587-9380
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 2DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Lori Cook, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Lori Cook was notified by telephone and arrived later to assist with the visit.

The facility is an Adult Residential Facility licensed for six ambulatory clients. There are currently two clients in care, one of which is present throughout the visit while the second client was observed returning from day program during the visit. The facility is a one-story home with three bedrooms assigned to clients, one of which is vacant. Clients shared one common bathroom. There are two additional staff rooms. Facility's interior appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility has extra linens and hygiene supplies for all two clients. Hot water measured at 150 degrees Fahrenheit in the bathroom used by clients, type A citation issued. LPA observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food as required by regulations. LPA observed hallways and walkways were free of obstruction. There are no bodies of water on the premises

LPA observed the fire extinguisher mounted on the dining room wall is charged and has a maintenance tag dated 2024. Staff and LPA tested smoke and carbon monoxide detectors which were found to be operational. Cleaning products and sharp instruments are stored in a locked cabinet in the kitchen. Medication for each client is kept locked and secured in a locked medication cart in the dining room. The backyard has one shaded seating area, and the exit gate is unlocked and unobstructed.

LPA reviewed two clients’ files and medications as well as P&I records which were verified to correspond to the amount noted on the ledgers. LPA reviewed three staff files. All files of staff and clients contained all required documentation. All current staff members and individual residing on the premises are cleared and associated. CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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 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: DISTOR'S RESIDENTIAL CARE II
FACILITY NUMBER: 300613018
VISIT DATE: 12/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUED FROM LIC809
Medication is observed to be stored in bubble packs, however staff is observed to prepare administration doses ahead of time in small cups that are not stored securely. Type B citation issued.

The Emergency and Disaster Plan was reviewed along with documentation of fire and emergency drills conducted monthly throughout 2024. Infection Control and Emergency and Disaster plans require an update, copies of the adequate forms provided.

One type A and one type B deficiencies are cited during today's inspection visit. An exit interview was conducted and a copy of this report along with appeal rights were provided to the facility staff.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/18/2024 03:49 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/18/2024 at 03:10 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: DISTOR'S RESIDENTIAL CARE II
FACILITY NUMBER: 300613018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as water in both the bathroom used by clients and in the kitchen measured above 150F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
1
2
3
4
Licensee will adjust the water heater thermostat and provide documentation of water measuring below 120F to LPA.
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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/18/2024 03:49 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/18/2024 at 03:23 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: DISTOR'S RESIDENTIAL CARE II
FACILITY NUMBER: 300613018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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:
Deficient Practice Statement
1
2
3
4
Based on observation and staff interview, the licensee did not comply with the section cited above as staff were observed and stated to place pre-poured medication outside the central storage pending administration, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
1
2
3
4
Licensee to conduct an updated in-service on medication administration and security requirements. Documentation to be provided to LPA before the plan of corrections due date.
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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5