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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001358
Report Date: 09/06/2022
Date Signed: 09/06/2022 03:46:25 PM


Document Has Been Signed on 09/06/2022 03:46 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
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:
09/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Lead Caregiver - Emelyn ReadTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were 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 conduct tour, and receive and sign report.

As of 9/6/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was also observed entrance. LPA observed the Administrator's Certificate for Rizalina Reyes, which expires on 6/30/23.

LPA De Perio toured the interior and exterior portions of the facility with LG Read. The facility is a two level structure and is licensed for 6 non-ambulatory, 0 bedridden and 4 hospice. LPA De Perio toured the second level of facility and observed no residents residing on the second floor and verified that the second level is not for resident use.

For this visit, there are a total of 4 residents in care, 2 on hospice, 0 bedridden. All 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. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 109.8 degrees Fahrenheit and hand washing signs were also posted in each restroom.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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: 09/06/2022
NARRATIVE
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Fire extinguisher was charged, mounted and located in the kitchen.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which was self-closing and self-latching. A swimming pool was observed to be in the backyard, of which there is a locked gate surrounding it.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Reyes. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Reyes to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations and Appeal Rights were printed and provided.

LPA De Perio advised AD Reyes to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Reyes via telephone and CG Read and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/06/2022 03:46 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
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87365(h)(2)
87365(h)(2) Incidental Medical and Dental Care

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and file review, the 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. LPAs observed resident 1 (R1) having possession of tubes of prescribed ointment that is used orally and topically. LPA also observed an open bottle of Milk of Magnesia Suspension in the kitchen. This poses an immediate threat on the health and safety of the residents in care.
POC Due Date: 09/20/2022
Plan of Correction
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CG removed ointments from R1’s room and locked the bottle of Milk Magnesia Suspension. Threat reduced. Administrator will provide training to staff on regulations cited. Licensee will comply with the POC on or by 9/20/2022 and submit proof to assigned LPA and Community Care Licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/06/2022 03:46 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
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms, and other items which could post a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 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. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee will lock and ensure that all toxins and disinfectants are inaccessible to residents in care. CG removed all disinfectants and transferred them into a locked room. Threat reduced. Licensee will comply with the POC on or by 9/20/2022 and submit proof to assigned LPA and Community Care Licensing.
Type A
Section Cited
CCR
87705(f)(1)
87705(f)(1) Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee failed to lock knives, and other items that could constitute a danger to the resident(s) which could post a danger. LPA observed knives, sharps and scissors in an unlocked kitchen drawer. CG removed all sharp items and knives and placed it in a locked cabinet. Threat reduced. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee will lock and ensure all sharps and knives are inaccessible to residents in care. Licensee will comply with the POC on or by 9/20/2022 and submit proof to assigned LPA and Community Care Licensing.

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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5