306001358-9-27-2024-22-AS-ARJR-D9HUN8-20240927154331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001358
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:43:38 PM

Document Has Been Signed on 09/27/2024 03:43 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:	PATCHWORK QUILT GUEST HOME FOR THE ELDERLY, THE		FACILITY NUMBER:	306001358
ADMINISTRATOR:	RIZALINA REYES		FACILITY TYPE:	740
ADDRESS:	23565 DURYEA DR.		TELEPHONE:	(949) 455-1326
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	09/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Julita Andrade-Caregiver, Rizalina Reyes-Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Julita Andrade. Administrator (AD) Rizalina Reyes arrived shortly after.

For today’s visit, LPA observed a total of five residents in care and two staff members on duty.

LPAs toured the interior and exterior portions of the facility with Caregiver Andrade. The facility is a two-story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of five bedrooms, of which four are resident bedrooms, and one is a bedroom for staff. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of three restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 105.3-106.7 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the kitchen and one by the Residents' bedroom hallway.

During today's visit LPAs observed as residents were watching television.

LPAs observed the emergency disaster and evacuation plan which is located by kitchen/dining room. Facility had back-up emergency food and water supply.

CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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: PATCHWORK QUILT GUEST HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 306001358
	VISIT DATE: 09/27/2024

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LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. LPA observed a pool which fenced by a 5 feet height metal fence.

LPAs reviewed five resident and three staff files. LPAs interviewed residents and staff present.

During today's visit LPAs consulted with AD regarding the updated Health Screening Report-Facility Personnel (LIC503). LPA informed AD to use the updated LIC503.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

LPAs advised AD Rizalina to use the general email address:

CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Rivas.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/27/2024 03:43 PM - It Cannot Be Edited

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: PATCHWORK QUILT GUEST HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 306001358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA did not observe documentation of the quarterly emergency drills.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Licensee to email updated proof of quarterly drills by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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