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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613262
Report Date: 05/22/2024
Date Signed: 05/22/2024 11:41:08 AM

Document Has Been Signed on 05/22/2024 11:41 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:NEW ERA GUEST HOMEFACILITY NUMBER:
300613262
ADMINISTRATOR/
DIRECTOR:		GUTIERREZ, JOSEFINA P.FACILITY TYPE:
740
ADDRESS:12692 BLACKTHORN ST.TELEPHONE:
(714) 537-1282
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 4DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Josefina GutierrezTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Michael Tea for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Administrator (AD) Josefina Gutierrez and discussed the purpose of the inspection.

LPAs reviewed Infection Control requirements. At about 8:45AM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and storage areas and observed the following: Structure: facility is a 6-bedroom, 4-bathroom, one-story house with no garage. There is a back yard with a patio cover for the residents. LPAs and AD observed 2 staff and 4 residents present at the facility. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPAs inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 113 and 118 degrees F in the 3 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the hallway closet, after corrections. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:45AM, LPAs reviewed 4 resident files and 2 staff files, interviewed 1 resident and 1 staff as all other residents were sleeping and staff were unavailable, and inspected medications for 4 residents. Facility does not handle resident money.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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 8
Document Has Been Signed on 05/22/2024 11:41 AM - It Cannot Be Edited


Created By: Sean Haddad On 05/22/2024 at 10:59 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: NEW ERA GUEST HOME
FACILITY NUMBER: 300613262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, R1 is bedridden per their physician's report dated 10/25/23 but the facility does not have a bedridden fire clearance, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee stated they will submit an LIC200 requesting a bedridden fire clearance, a paragraph attachment describing which room will be for bedridden residents, a new floor plan reflecting the change, and a $25 check made out to CA Department of Social Services by POC due 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:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 11:41 AM - It Cannot Be Edited


Created By: Sean Haddad On 05/22/2024 at 10:59 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: NEW ERA GUEST HOME
FACILITY NUMBER: 300613262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the facility does not have an Infection Control Plan, which poses a potential health risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee stated they will review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan to LPA by POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and documents, the fire extinguisher has not been inspected or replaced since 2022, which poses a potential safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee stated they will purchase and install a new fire extinguisher and submit proof to LPA by POC 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/22/2024 11:41 AM - It Cannot Be Edited


Created By: Sean Haddad On 05/22/2024 at 10:59 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: NEW ERA GUEST HOME
FACILITY NUMBER: 300613262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee does not have nightlights anywhere in the facility, which poses a potential safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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 Licensee stated they will purchase and install nightlights and will submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87309(a)
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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Based on observation, the licensee did not ensure toxins were secured in the laundry room when staff could not locate the key to the lockable storage closet during the inspection, but the residents are all non-ambulatory and the facility has 2 staff caring for 4 residents to ensure safety, which poses a potential safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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During the inspection, the licensee secured these items and LPA confirmed. POC CLEARED.
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:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/22/2024 11:41 AM - It Cannot Be Edited


Created By: Sean Haddad On 05/22/2024 at 10:59 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: NEW ERA GUEST HOME
FACILITY NUMBER: 300613262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure medications were secured in the non-lockable staff bedroom, but the residents are all non-ambulatory and the facility has 2 staff caring for 4 residents to ensure safety, which poses a potential safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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During the inspection, the licensee secured these items and LPA confirmed. POC CLEARED.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee did not ensure S1 and S2 received their 20 hour annual training, which poses a potential health risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee stated they will have staff complete the training and submit proof to LPA by POC 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/22/2024 11:41 AM - It Cannot Be Edited


Created By: Sean Haddad On 05/22/2024 at 10:59 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: NEW ERA GUEST HOME
FACILITY NUMBER: 300613262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee's PUB475 is letter sized, which poses a potential personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee stated they will purchase and post a PUB475 of the required size and send proof to LPA by POC 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/22/2024 11:41 AM - It Cannot Be Edited


Created By: Sean Haddad On 05/22/2024 at 10:59 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: NEW ERA GUEST HOME
FACILITY NUMBER: 300613262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on documents and admission, the facility does not have a current LIC610E and cannot locate their full emergency disaster plan, which poses a potential safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee stated they will complete and post an updated LIC610E using the new 9-page form and submit proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on documents and admission, the facility has not conducted an emergency disaster drill since January 1, 2020, which poses a potential safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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3
4
Licensee stated they will conduct an emergency disaster drill as required and submit proof to LPA by POC due date and will conduct drills quarterly moving forward.
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:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
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: NEW ERA GUEST HOME
FACILITY NUMBER: 300613262
VISIT DATE: 05/22/2024
NARRATIVE
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During the inspection, LPAs and AD observed the following: based on documents, the facility does not have an Infection Control Plan; based on observation and documents, the fire extinguisher has not been inspected or replaced since 2022; based on documents, R1 is bedridden per their physician's report dated 10/25/23 but the facility does not have a bedridden fire clearance; based on observation, the licensee does not have nightlights anywhere in the facility; based on observation, the licensee did not ensure toxins were secured in the laundry room when staff could not locate the key to the lockable storage closet during the inspection, but the residents are all non-ambulatory and the facility has 2 staff caring for 4 residents to ensure safety; based on observation, the licensee did not ensure medications were secured in the non-lockable staff bedroom, but the residents are all non-ambulatory and the facility has 2 staff caring for 4 residents to ensure safety; based on documents, the licensee did not ensure S1 and S2 received their 20 hour annual training; based on observation, the licensee's PUB475 is letter sized; based on documents and admission, the facility does not have a current LIC610E and cannot locate their full emergency disaster plan; and based on documents and admission, the facility has not conducted an emergency disaster drill since January 1, 2020.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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