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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000089
Report Date: 04/02/2024
Date Signed: 04/02/2024 03:53:44 PM


Document Has Been Signed on 04/02/2024 03:53 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VALLEY GUEST HOMEFACILITY NUMBER:
306000089
ADMINISTRATOR:DULCE S.ARGOSINOFACILITY TYPE:
740
ADDRESS:10413 OWL CIRCLETELEPHONE:
(714) 963-7423
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Emma Firme, Licensee/AdministratorTIME COMPLETED:
04:00 PM
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On today's date, Licensing Program Analysts (LPAs) LPA Rosie Quiroz and LPA Michael Tea made an unannounced visit on this day for the purpose of conducting an Annual Required-1 year inspection visit. LPAs were greeted by Caregiver 1 and met with Licensee/Administrator (L/AD) Emma Firme and discussed purpose of the visit.
The facility is a one story home which consists of: 4 private resident bedrooms, 1 shared resident bedroom, 1 caregiver bedroom, 1 bedroom designated for Administrator Headquarters, 3 bathrooms for residents and staff, living-room, family room, kitchen with dining area, back yard with ample shade and outdoor furniture, garage with operational washer and dryer.
The facility is licensed for a capacity of 6 Non-Ambulatory residents, and has a hospice waiver for 4 residents. There is currently (1) one resident currently receiving hospice care services.
Administrator Emma Firme has a current Administrator's certificate which expires on 9/25/2024.
LPAs along with Administrator Emma Firme toured the interior and exterior of facility. LPAs observed kitchen for proper sanitation and cleanliness. LPAs observed Sharp objects locked and secured in cabinet in kitchen area, and observed toxin substances to be locked and inaccessible to residents in care in locked and secured closet in garage area. The food was observed to meet the minimum requirement of two days perishable and seven days nonperishable food supply for residents in care.
Six of six resident bedrooms were observed to have required furnishings including but not limited to: lamp, bed, mattress, night stand and clean linen. LPA Quiroz interacted and interviewed 6 of 6 residents during facility tour. The water temperature in 3 of 3 resident bathrooms were measured to be within normal limits. The Grab bars and non-slip mats were observed in resident bathrooms. Room temperature inside the facility was recorded to be 71 degrees F.
The outside grounds were inspected during facility tour, and no bodies of water were observed. No pool available at this facility. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
CONTINUED NEXT LIC 809-C PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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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: VALLEY GUEST HOME
FACILITY NUMBER: 306000089
VISIT DATE: 04/02/2024
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CONTINUED...LPAs observed two fire extinguishers mounted and charged in garage area, which were last serviced on 7/06/2023. LPAs observed and tested functional and operational carbon monoxide and smoke alarms.
(AD) Emma Firme reports fire drills are conducted quarterly with staff and residents. Last facility fire drill was conducted on March 4,2023.
(AD) Emma Firme reported offering the following indoor and outdoor activities at the facility according to weather conditions: "walks in the morning, puzzles, individual reading, painting and one resident loves to quilt." LPA Quiroz reviewed whether the facility is operating within capacity limitations and reviewed repeated violations, no repeated violations assessed.
During today's visit, LPAs reviewed six of six resident records, centrally stored medications and three of three personnel files. Resident and personnel files were found to be within Title 22 California Code of Regulations.

Based on the observations made during today’s visit; there are no deficiencies being cited per Title 22 Division 6 of the California Code of Regulations. This report was read and reviewed with (L/AD) Emma Firme, and a copy of this report, LIC 858, LIC 859 were provided at exit.


SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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