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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002201
Report Date: 03/21/2022
Date Signed: 04/06/2022 12:08:31 PM


Document Has Been Signed on 04/06/2022 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PATCHWORK QUILT GUEST HOME IIFACILITY NUMBER:
306002201
ADMINISTRATOR:RIZALINA S. REYESFACILITY TYPE:
740
ADDRESS:25182 CAMPO ROJOTELEPHONE:
(949) 581-7049
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:
Rizalina Reyes, administrator (telephone call)
Trinia Renada, Caregiver		TIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Claudia Gutierrez made an unannounced visit to the facility in order to conduct a required annual inspection. LPAs arrived at facility, were greeted and granted entry by Trinia Renada, caregiver after explaining the purpose of the visit. Administrator Rizelina Reyes was called during the visit but was unable to assist as she was performing the groceries resupply for the facility.

At approximately 11:15am, LPAs accompanied by caregiver toured the inside and outside of the facility. There are currently six (6) residents in care, one of (1) of which is currently on hospice. Residents are observed to be relaxing in their bedroom or in the common areas are appear well taken care of. The bedrooms include all necessary components and sufficient quantity of linen is observed also. Both bathrooms are equipped with grab bars and slip mats. Facility appears to be clean, sanitary and free of odors in all areas inspected. Cleaning supplies are observed in an unsecured cabinet under the sink. The box in which sharp instruments are stored is observed to be missing a lock. The door leading to the garage is also left open during the daytime in spite of the presence of cleaning supplies and detergent there. Caregiver indicates that it is being locked at night only.

LPAs observed the facility has COVID-19 Precautions posters and required department postings. Hand washing signs however are not being displayed in the residents' bathrooms. Facility has an adequate supply of PPE and emergency supplies. A LIC808 Mitigation Plan has been submitted on 07/07/2021.
LPAs observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored under lock. LPAs observed medication cups with unpacked pills are being prepared for each meal and are not adequately marked to avoid medication administration errors. LPAs toured the outside of the facility. Outdoor furniture is present for the residents' enjoyment in the backyard.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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 II
FACILITY NUMBER: 306002201
VISIT DATE: 03/21/2022
NARRATIVE
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Construction is being completed on the patio shade with lumber and other building materials being stored on the ground in the backyard. Clutter and broken furniture are also observed in the yard and in the alley besides the house. The gates on the side of the house iareself-latching and can easily be opened in an evacuation.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is also issued in regards to the presence of construction material and clutter in the backyard. This report was reviewed with facility representative and a copy of this report and appeals right was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/06/2022 12:08 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 II
FACILITY NUMBER: 306002201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
- A box storing sharp instruments is observed in a kitchen drawer. The box is missing its lock and cannot be secured. Drawer does not lock either.
- Cleaning supplies are observed stored under the kitchen sink. Cabinet is not equipped with a lock or any kind of securing device.
- Access door to the garage is left open during daytime, despite the presence of detergent and other cleaning supplies
Deficient Practice Statement
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Based on observation made during today's visit, the licensee did not comply with the section cited above in the three described instances, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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Access to all potentially dangerous items listed above needs to be restricted and secured. Licensee will provide documentation of the corrections being implented to LPA by POE due date.

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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/06/2022 12:08 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 II
FACILITY NUMBER: 306002201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(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: LPAs observed prepoured medication being placed on the dining table with the resident not yet present for the corresponding meal. Cuplet was later placed on a countertop and left there unattened
Deficient Practice Statement
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Based on todays's observations, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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Pre-poured medication will remain centrally stored until the resident is seated and medication is ready to be administred immediately.
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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4