306002525-9-9-2024-22-AS-MTEA-D8XW3N-20240909165614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002525
Report Date: 09/09/2024
Date Signed: 09/09/2024 04:56:36 PM

Document Has Been Signed on 09/09/2024 04:56 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:	NEW ERA GUEST HOME II		FACILITY NUMBER:	306002525
ADMINISTRATOR:	JOSEFINA GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	9831 ROYAL PALM BLVD.		TELEPHONE:	(714) 583-8643
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 3	DATE:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	Josefina Gutierrez		TIME COMPLETED:	05:10 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) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At 1:17 PM LPA Tea was greeted and granted entry into the facility by caregiver, Lesliroy Briones and explained the reason for the visit. During today’s visit, LPA met with Josefina Gutierrez the administrator of the facility. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are three residents, of which one is on hospice during today's visit. Around 1:31 PM LPA reviewed one staff files and training record. LPA reviewed three of three resident records. Residents files and staff files contained all required documentation. Administrator certificate expires on November 17, 2024. At 2:14 PM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet by the laundry area. Medications are being administered per physician order. LPA Tea along with the Administrator toured the facility at 2:23 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 6 resident bedrooms, 2 private bedrooms, 5 full bathrooms, living room, dining room, kitchen and garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational except for one in the common area was not working properly but will be replaced. The nearby rooms have working fire alarms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. During the facility tour, LPA noticed a private room of a non-associated relative residing at the facility. LPA checked Guardian and the personnel roster print out on LIS and residing relative is not cleared or associated with the facility. LPA advised administrator that the relative must obtain background clearance in order to stay at the facility. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured at 116.4 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Annual Report continuation on LIC 809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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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Document Has Been Signed on 09/09/2024 04:56 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: NEW ERA GUEST HOME II	FACILITY NUMBER: 306002525
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of facility tour licensee's niece is living at the facility and has no background clearance and is not associated on Guardian. This is an immediate health and safety risk to residents in care.
	POC Due Date: 09/10/2024
	Plan of Correction
1 2 3 4	Licensee will get background clearance for niece Charito Paca who currently resides at the facility and have her associated to the facility.

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.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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: NEW ERA GUEST HOME II	FACILITY NUMBER: 306002525
	VISIT DATE: 09/09/2024

NARRATIVE

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Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to residents in a cabinet by the laundry area. Fire extinguisher in the kitchen was fully charged. Kitchen appliances are working except for kitchen stove had one burner not working and advise administrator to repair and clean the burner.

LPA toured the outside grounds and there is ample seating and the two exit gates on both sides of the facilities are self latching and operational. LPA observed emergency food and water supply in the garage. Facility provides activities based on their personal choice. Residents participate in numerous activities like walking around the facility and the neighborhood. At the time of the visit, LPA observed residents watching television.

LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and civil penalties are being assessed.

An exit interview was conducted with Josefina Gutierrez and a copy of these reports were given to the facility along with a copy of the LIC809C, LIC 858; 859;809-D, LIC9102TV and Appeal Rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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