Community Care Licensing

Document Has Been Signed on 08/07/2023 03:10 PM - It Cannot Be Edited

FACILITY NAME:	PROMISES GUEST VILLAGE		FACILITY NUMBER:	306000106
ADMINISTRATOR:	DANTE ENCARNACION		FACILITY TYPE:	735
ADDRESS:	1315-1321 ANAHEIM BLVD.		TELEPHONE:	(714) 774-1544
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY: 40		CENSUS: 40	DATE:	08/07/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Maria Rizza Engreso		TIME COMPLETED:	03:30 PM

SUPERVISORS NAME: Armando J Lucero LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023

Link to Parent Document Below:

FACILITY NAME: PROMISES GUEST VILLAGE	FACILITY NUMBER: 306000106
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/08/2023 Section Cited CCR 80019(e)(2)	1 2 3 4 5 6 7	Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 80019(f). This requirement is not	1 2 3 4 5 6 7	Licensee to ensure all staff have proper transfer of their criminal record clearance and submit written proof to LPA by POC due date of 08/08/2023.
	8 9 10 11 12 13 14	met as evidenced by: based on record review & interview the Licensee/AD did not obtain a transfer of a criminal clearance for Staff Lizbeth Diaz & Raul Ramirez. This poses an immediate risk to the health & safety of clients in care.	8 9 10 11 12 13 14	CIVIL PENALTY ASSESSED
Type A 08/08/2023 Section Cited CCR85065	1 2 3 4 5 6 7	Personnel Requirements The licensee shall employ staff .....This regulation was not met as evidenced by: Based on observation and interview with staff and clients, it was determined that there is no staff on duty for 40 clients, with meals, clean/maintain the facility, conduct activities and provide care	1 2 3 4 5 6 7	Licensee/AD will submit plan on hiring and maintaining adequate staffing and provide updated LIC 500 Personnel Report documenting proof of correction by due date of 08/08/2023.
	8 9 10 11 12 13 14	and supervision to all clients. Licensee/AD did not have adequate staffing to meet the clients’ needs. This poses an immediate risk to clients in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023

Link to Parent Document Below:

FACILITY NAME: PROMISES GUEST VILLAGE	FACILITY NUMBER: 306000106
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/11/2023 Section Cited CCR 80061(b)	1 2 3 4 5 6 7	Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified...a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the below shall be	1 2 3 4 5 6 7	Licensee/AD agreed to read entire regulation and submit proof of understanding by POC due date of 08/11/2023.
	8 9 10 11 12 13 14	submitted to the licensing agency within seven days following occurrence...This requirement was not met as evidenced by: CCL received 2 death reports only after LPA became aware of incidents and requested reports. This poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
Type B 08/31/2023 Section Cited CCR80087(a)	1 2 3 4 5 6 7	BUILDINGS AND GROUNDS:The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. Client bathroom floor observed with water damage around toilet and raised in areas that could be a tripping hazard, bathroom sink	1 2 3 4 5 6 7	Licensee/AD to submit plan on repair or replace broken items and forward to CCL by on or before the POC date 08/11/2023.
	8 9 10 11 12 13 14	coming off wall, broken closet doors and dressers which are broken or are missing drawers in several clients rooms which poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023