306002201-3-22-2024-22-AS-CDPO-D3M5BP-20240322194903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002201
Report Date: 03/22/2024
Date Signed: 03/22/2024 07:49:17 PM

Document Has Been Signed on 03/22/2024 07:49 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:	RIZALINA S. REYES		FACILITY TYPE:	740
ADDRESS:	25182 CAMPO ROJO		TELEPHONE:	(949) 581-7049
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	03/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	06:43 PM
MET WITH:	Staff on Duty - Trinia Granada		TIME COMPLETED:	08:10 PM

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by staff on duty (S1) Trinia Granada. S1 notified facility administrator (AD) Rizalina Reyes about visit, however AD was unable to be present, therefore provided consent for S1 Granada to receive and sign report.

For today’s visit, LPA observed a total of 5 residents in care and 2 staff members on duty.

LPA observed the Administrator's Certificate for facility administrator (AD) Rizalina Reyes which expires on 06/20/2025. LPA observed the PUB475 "See Something Say Something" poster located at the entrance and in the hallway.

LPA De Perio toured the interior and exterior portions of the facility with S1 Granada. The facility is a single level structure and is licensed for 6 residents, of which 4 may be on hospice. For this visit, there are a total of 5 residents in care. There are a total of 5 bedrooms, of which 2 are private resident rooms, 2 are shared resident rooms, and 1 room designated for staff. LPA De Perio 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. It was observed that there are a total of 2 restrooms in the facility. 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 109.7 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 extinguisher was charged, mounted and located in the kitchen.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway. Facility had back-up emergency food and water supply, located in the garage and in the kitchen.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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 II	FACILITY NUMBER: 306002201
	VISIT DATE: 03/22/2024

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

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 both were self-closing and self-latching. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with S1 Granada.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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