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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001297
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:08:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/03/2024 12:08 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:DISTOR'S RESIDENTIAL CAREFACILITY NUMBER:
306001297
ADMINISTRATOR/
DIRECTOR:		LORI J. DISTORFACILITY TYPE:
735
ADDRESS:22845 WILLARD AVETELEPHONE:
(949) 472-2062
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
12/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Lori Cook, Administrator (via phone)TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the purpose of the visit. Administrator Lori Cook was notified by telephone and was unable to attend to the visit as she was attending a medical appointment with a client from another licensed location.

The facility is an Adult Residential Facility licensed for six ambulatory clients. There are currently three clients in care, only one of which is present during the visit. Both other clients are at day program during the present visit. The facility is a one-story home with three shared bedrooms assigned to clients, one of which is currently vacant. Clients shared one common bathroom. There is an additional staff room along with a bathroom used by live-in staff members. Facility's interior appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility has extra linens and hygiene supplies for all three clients. Hot water measured at the most at 103 degrees Fahrenheit in the bathroom used by clients, type B citation issued. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food was available as required by regulations. LPAs observed hallways and walkways were free of obstruction. There are no bodies of water on the premises

LPAs observed the fire extinguisher mounted on the living room wall is charged and has a maintenance tag dated 2024. Staff and LPAs tested smoke and carbon monoxide detectors which were found to be operational. Cleaning products and sharp instruments are stored in a locked cabinet in the kitchen. Medication for each client is kept locked and secured in a locked medication cart positioned in the dining room. The backyard has one shaded seating area, and the exit gates are unlocked and unobstructed. LPAs reviewed all three clients’ files and medications as well as P&I records which were verified to correspond to the amount noted on the ledgers. Receipts also match the amounts and dates logged in the ledger. LPAs reviewed two staff files. CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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: DISTOR'S RESIDENTIAL CARE
FACILITY NUMBER: 306001297
VISIT DATE: 12/03/2024
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CONTINUED FROM LIC809
All files of staff and clients contained all required documentation. All current staff members are cleared and associated.

The Emergency and Disaster Plan was reviewed along with documentation of fire and emergency drills conducted monthly until February 2024. No documentation of current quarterly drills provided. Type B citation issued. Infection Control and Emergency and Disaster plans require an update, copies of the adequate forms provided.

Two type B deficiencies are cited during today's inspection visit. An exit interview was conducted and a copy of this report along with appeal rights were provided to the facility staff.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/03/2024 12:08 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/03/2024 at 11:48 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: DISTOR'S RESIDENTIAL CARE
FACILITY NUMBER: 306001297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
80088(e)(1)

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(e)(1) "Faucets used by clients for personal care such as shaving and grooming shall deliver hot water (...) of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)". This requirement is not met as evidenced by:
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Licensee will get the water heater inspected and ensure delivery of water meeting the regulatory requirement.
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Based on observation, the licensee did not comply with the section cited above as water in the clients' bathroom never measured higher than 103.2F during the visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/03/2025
Section Cited
HSC1565(c)

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(c) A facility shall conduct a drill at least quarterly for each shift.(...) Documentation of the drills shall include the date, the type of emergency (...) and (...) the names of staff participating in the drill. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
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Licensee to conduct an additional drill in 2024. Drills will be scheduled and conducted quarterly in 2025.
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Based on staff interviews and record review, the licensee did not comply with the section cited above as no documentation of drills conducted after February 2024 could be provided, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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