306000833-8-19-2024-22-AS-MTEA-D8AVHF-20240819162706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000833
Report Date: 08/19/2024
Date Signed: 08/19/2024 04:27:37 PM

Document Has Been Signed on 08/19/2024 04:27 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:	MISSY'S GUEST HOME		FACILITY NUMBER:	306000833
ADMINISTRATOR/ DIRECTOR:	RODOLFO G. MENDOZA		FACILITY TYPE:	735
ADDRESS:	9531 BIXBY AVENUE		TELEPHONE:	(714) 534-7571
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 6		CENSUS: 1	DATE:	08/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Maria Mendoza		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Maria Mendoza. The facility is licensed for 6 ambulatory clients. Currently there is one client living here during today's visit.

At 1:35 PM, LPA Tea reviewed one client file and two staff files. Client files and staff files contained all required documentation except one minor issue with the admission agreement on file for the client. The form LIC604 was used as the admission agreement, LPA advised that the LIC604 is not an admission agreement but to be used only a a guide to create an admission agreement. The administrator certificate expires on April 4, 2025

LPA Tea along with the administrator toured the facility around 2:50 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home that consist of five bedrooms, three are reserved for client bedrooms, and two are staff rooms, and two and a half bathrooms. The facility has a kitchen, dining room, and living room, family den and a garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured around 105.8 F degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a storage cabinet in the family den. LPA also observed toxin substances to be secured and locked and inaccessible to clients in a storage closet in the family den.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MISSY'S GUEST HOME	FACILITY NUMBER: 306000833
	VISIT DATE: 08/19/2024

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The fire extinguisher between the laundry area and kitchen is fully charged. The facility’s last fire drill was conducted on August 1, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. The client helps with watering and cleaning the yard with the administrator. LPA observed emergency supplies, food, and water in the garage and in the family den area. LPA Tea observed the client leaving for a walk in the neighborhood.

LPA reviewed medication storage and administration. Medications are stored in a locked storage cabinet in the family den. Medications are being administered per physician order. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with administrator Maria Mendoza and a copy of this report LIC809, 809-C, LIC858, LIC859, and LIC9102TV was read and provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC809 (FAS) - (06/04)

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