306002817-8-15-2022-22-AS-KSGH-CHBPTG-20220815113554

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002817
Report Date: 08/15/2022
Date Signed: 08/15/2022 11:36:09 AM

Document Has Been Signed on 08/15/2022 11:36 AM - 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:	GLORIOUS HOME #2		FACILITY NUMBER:	306002817
ADMINISTRATOR:	PRISCILLA DELAGNEAU		FACILITY TYPE:	740
ADDRESS:	24672 ARGUS DRIVE		TELEPHONE:	(949) 916-2079
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 2	DATE:	08/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Crystal Delagneau, staff member Iris Blanco Lucero, caregiver Patricia Lucero Marquez, caregiver		TIME COMPLETED:	11:55 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	On 08/15/2022 at 9:45am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by caregiving staff after being temperature checked and signing in. LPA explained the purpose of the visit. Caregiving staff called administrator Chester Delagneau to notify him of the visit. Administrator recently tested positive for COVID-19 and has not yet been cleared. Staff member Crystal Delagneau arrived later to assist with the visit. At approximately 10:35am, LPA accompanied by employee Crystal Delagneau toured the physical plant of the facility. LPA observed a check-in station where visitor temperatures are being documented. There are currently two (2) residents in care, one (1) of which is receiving hospice care. The residents are observed relaxing in the common area of the facility and appear clean and well taken care of. The four (4) bedrooms include all necessary components. The bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are stored in a kitchen cabinet secured by a magnetic lock. LPA observed a sufficient supply of food and water present. A 30-day supply of medication is centrally stored in kitchen cabinet secured by magnetic locks. Cleaning supplies are located in the locked laundry room. LPA observed the facility has COVID-19 Precautions posters and all required department postings as well as hand-washing signs in the bathrooms. Facility has an adequate supply of PPE. A fire extinguisher is present and charged. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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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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: GLORIOUS HOME #2	FACILITY NUMBER: 306002817
	VISIT DATE: 08/15/2022

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CONTINUED FROM LIC809 FORM

Caregiving staff present is correctly cleared and associated in Guardian. Staff association for Crystal Delagneau needs to be added. LPA toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture is present for the residents' enjoyment. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water are present on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Two Technical Advisories are being issued, regarding COVID-19 positive cases reporting as well as staff clearance and association. This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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