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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001358
Report Date: 09/23/2022
Date Signed: 09/23/2022 10:58:58 AM


Document Has Been Signed on 09/23/2022 10:58 AM - 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:PATCHWORK QUILT GUEST HOME FOR THE ELDERLY, THEFACILITY NUMBER:
306001358
ADMINISTRATOR:RIZALINA REYESFACILITY TYPE:
740
ADDRESS:23565 DURYEA DR.TELEPHONE:
(949) 455-1326
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Lead Caregiver - Emelyn Read TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 09/06/2022. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty, who contacted facility administrator (AD) Rizalina Reyes about visit. AD Reyes was unable to be present during time of visit, but provided consent for Lead Caregiver (CG) Emelyn Read to receive and sign report.

For today's visit, LPA De Perio verified that there are currently 4 residents in care and 2 staff members present.

On 9/6/22, LPA De Perio observed that facility failed to keep the centrally stored medication in a safe and locked place that is not accessible to residents in care, other than employees responsible for the supervision of centrally stored medication. LPA observed resident 1 (R1) having possession of tubes of prescribed ointment that is used orally and topically. LPA De Perio reviewed R1’s files, which did not indicate or specify that R1 was able to have possession of any prescribed items. LPA also observed an open bottle of Milk of Magnesia Suspension in the kitchen.

*Deficiency cited under Title 22 Regulation 87365(h)(2) pertaining to Incidental Medical and Dental Care has been CLEARED. Licensee has provided staff with training on 9/12/22 on this regulation and LPA De Perio observed that facility has secured medications in a location that is inaccessible to residents in care.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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: PATCHWORK QUILT GUEST HOME FOR THE ELDERLY, THE
FACILITY NUMBER: 306001358
VISIT DATE: 09/23/2022
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On 9/6/22, LPA De Perio observed that licensee failed to lock disinfectants, cleaning solutions, poisons, and other items which could post a danger. LPA observed cleaning supplies and disinfectants stored in an unlocked cabinet located under the bathroom sink. LPA also observed bottles of rubbing alcohol in an unlocked kitchen cabinet.

*Deficiency cited under Title 22 Regulation 87309 pertaining to Storage Space has been CLEARED. Licensee has provided staff with training on 9/12/22 on this regulation and LPA De Perio observed that facility has secured disinfectants, cleaning solutions, and poisons in a locked location and is inaccessible to residents in care.

On 9/6/22, LPA De Perio observed that licensee failed to lock knives, and other items that could constitute a danger to the resident(s) which could post a danger. LPA De Perio observed knives, sharps and scissors in an unlocked kitchen drawer.

* Deficiency cited under Title 22 Regulation 87705(f)(1) pertaining to Care of Persons with Dementia has been CLEARED. Licensee has provided staff with training on 9/12/22 on this regulation and LPA De Perio observed that facility now has a locked box located in the kitchen of which is designated to secure knives and sharps.

LPA De Perio conducted an exit interview with caregiver Read, and AD Reyes via phone, and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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