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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000692
Report Date: 12/16/2024
Date Signed: 12/16/2024 02:50:54 PM

Document Has Been Signed on 12/16/2024 02:50 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:GOOD SAMARITAN GUEST HOME IIIFACILITY NUMBER:
306000692
ADMINISTRATOR/
DIRECTOR:		LEO / SUSAN CAMBIOFACILITY TYPE:
740
ADDRESS:26821 VIA GRANDETELEPHONE:
(949) 348-8967
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Leo Cambio, administratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by facility administrator Leo Cambio after stating the purpose of the visit.

There are currently five residents in care, none of which is receiving hospice care. LPAs observed residents relaxing in the facility’s common area or in their respective bedrooms. LPAs accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has two shared and one private bedrooms with one shared bathroom for residents and one shared bathroom for staff members. Bedrooms appeared clean and sanitary. LPAs observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and non-slip mats. Hot water temperature measured at 110F.

LPAs observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. LPA observed knives locked in a secure drawer. A fire extinguisher is verified to be charged and mounted to the wall. Annual maintenance is however not apparent. Staff stated the fire extinguisher was bought new earlier in 2024. Consultation provided. LPAs tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked cabinet in the staff bedroom. The attached garage is inaccessible to residents and is used for storage and for laundry. Cleaning supplies are stored in the garage.

LPAs and facility staff toured the outside of the facility and observed it to be free of obstructions. LPAs observed two shaded outdoor seating areas with furniture for resident use. The perimeter gates on one side of the property is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

CONTINUED ON FORM LIC809-C
Sheila SantosTELEPHONE: (714) 334-2062
Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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: GOOD SAMARITAN GUEST HOME III
FACILITY NUMBER: 306000692
VISIT DATE: 12/16/2024
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CONTINUED FROM FORM LIC809

LPAs reviewed five resident records which included all necessary components. LPAs reviewed resident medication records and found the Medication Administration Records to be outdated for one resident out of five. Prescription orders verified for all five residents. Consultation provided. LPAs reviewed two staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Infection Control and Emergency and Disaster plans were both reviewed and are complete and accurate. Fire and emergency drills are conducted quarterly. Drills are documented on the Emergency and Disaster Plan itself rather than on a separate document. Consultation provided.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Three consultations provided. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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