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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002292
Report Date: 04/04/2022
Date Signed: 04/05/2022 01:06:06 PM


Document Has Been Signed on 04/05/2022 01:06 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:LOIS GUEST HOMEFACILITY NUMBER:
306002292
ADMINISTRATOR:LOUIE DORMIDOFACILITY TYPE:
740
ADDRESS:17582 MEDFORD AVE.TELEPHONE:
(714) 730-9823
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 5DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Kenneth ForsythTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was granted entry into the facility by Administrator Kenneth Forsyth who confirmed there are currently no cases or exposures of COVID-19 within the facility.

Currently there are 5 residents living at the facility, of which one is receiving Hospice services. The facility is licensed for 6 non ambulatory residents. There is a sign-in procedure in place and hand sanitizer for use. LPA was screened upon entry into the facility. LPA observed staff were wearing face masks. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA observed the required Department posting on COVID-19 precautions at entrance of facility and/or throughout the facility. LPA toured resident rooms, all rooms were within regulations. Restrooms observed contained hand washing soap, toilet paper and paper towels. The proper hand washing signs were posted in the restrooms. Facility has operating smoke and carbon monoxide detectors. Facility's Fire Extinguisher was charged. LPA observed a copy of Administrators Certificate which expires on 02/15/2023. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted, and medication is stored in a locked file cabinet in dining room. Staff and Residents files are secured. Facility has 30 days supply of medications for the residents. Resident files were reviewed and required forms were current. The facility has a Mitigation Plan.

Based on observations made during today’s inspection, no deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with Administrators and a copy will be emailed.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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