306002201-3-6-2025-22-AS-BLOZ-DEHRJB-20250306120339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002201
Report Date: 03/06/2025
Date Signed: 03/06/2025 12:04:01 PM

Document Has Been Signed on 03/06/2025 12:04 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 II		FACILITY NUMBER:	306002201
ADMINISTRATOR/ DIRECTOR:	RIZALINA S. REYES		FACILITY TYPE:	740
ADDRESS:	25182 CAMPO ROJO		TELEPHONE:	(949) 581-7049
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	03/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Administrator Rizalina Reyes		TIME VISIT/ INSPECTION COMPLETED:	12:18 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Rizalina Reyes was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Rizalina Reyes has a valid Administrator certificate which expires on June 30, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for three. The facility is a single-story home with four resident bedrooms, two of which are shared, one staff bedroom, two shared resident bathrooms, a living room, a dining room, a kitchen, and an attached two car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed three residents in care, none of which are on hospice, and three care giving staff present. LPA observed residents relaxing in the living room as well as their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall in the resident hallway. LPA inspected the four resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed each resident has an internet device in their bedroom. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the two shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 65.6 and 132.2 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to residents in care. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The four top electric stove was operational. LPA observed knives and sharps are stored in a locked storage cabinet in the kitchen. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

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 II	FACILITY NUMBER: 306002201
	VISIT DATE: 03/06/2025

NARRATIVE

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A fire extinguisher is located in the kitchen and it was observed to be charged and serviced on September 4, 2024. LPA tested the individual smoke detectors and carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on October 1, 2024. The centrally stored medication is kept in a locked cabinet in the resident hallway. A First Aid kit was observed be stored in the locked cabinet and it was observed to be missing scissors, a thermometer, and a tweezer. The door leading to the attached two car garage is kept locked and inaccessible to resident. The garage is used for storage and laundry. LPA observed chemicals and toxins to be stored in the locked garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA and the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the north side and southside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all three resident files. LPA observed the facility did not have a Pre-appraisal on file for Resident #3 (R3). LPA observed the facility did not have a Reappraisal on file for Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3). LPA reviewed all three residents’ medication and medication records. LPA reviewed four staff files. LPA observed that 0 out of the 4 care giving staff had a valid CPR training card on file. LPA observed that 0 out of the 4 care giving staff did not conduct the required annual training for the year of 2024. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Rizalina Reyes. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2025 12:04 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 II	FACILITY NUMBER: 306002201
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, 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. LPA measured the hot water in the two resident bathrooms which measured between 65.6 and 132.2 degrees Farenheit.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	LPA observed AD call her plumber during the time of visit and schedule an appointment for later today. AD will send a picture using a thermometer of the hot water once repairs have been completed. POC cleared during visit.

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.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2025 12:04 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 II	FACILITY NUMBER: 306002201
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that 0 out of 4 care giving staff have a valid CPR training card. LPA spoke with AD who stated that none of the staff have a valid CPR training card.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to have all four care giving staff complete a valid CPR training. AD will submit proof of the CPR training card to LPA via email or fax by POC date. AD showed LPA proof of 1 out of the 4 care giving staff having a valid CPR training card. POC cleared at time of visit.

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the facility does not have a Preappraisal on file for Resident #3 (R3).
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to complete a Preappraisal for Resident #3 (R3) and submit proof of completion to LPA via email or fax by POC date. AD completed the Preappraisal for R3 dring the visit. POC cleared during time of visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2025 12:04 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 II	FACILITY NUMBER: 306002201
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the facility does not have a Reappraisal on file for Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3).
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to complete Reappraisals for Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3). AD will submit the Reappraisals to LPA via email or fax by POC date.

Type B

Section Cited

CCR

87411(c)

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	(c) Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that 0 out of the 4 care giving staff completed the required annual training for the year of 2024.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to have all the care giving staff to complete the required annual training. AD agreed to submit proof of the training to LPA via email or fax by POC 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.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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