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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002818
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:11:36 PM

Document Has Been Signed on 08/06/2024 05:11 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:GLORIOUS HOME #3FACILITY NUMBER:
306002818
ADMINISTRATOR/
DIRECTOR:		DELAGNEAU, CHESTERFACILITY TYPE:
740
ADDRESS:24726 ARGUS DRIVETELEPHONE:
(949) 581-1039
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Jeena Sharma, Administrator
Pardeep Sharma, Administrator		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the inspection. Administrator Jeena Sharma was also present and able to assist with the visit. The facility is currently undergoing a change of ownership with a pending application that was submitted in the days prior to the present annual. No pending license number has been provided at this time.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with two private bedrooms, two shared bedrooms and two shared bathrooms in addition to the facility's common living areas. All resident bedrooms have the required furnishing, bathrooms are equipped with grab bars and slip mats. LPA observed all beds have linens and blankets.

The backyard has a shaded area and the route of egress is free of clutter and obstructions. There are currently five residents admitted to the facility, two of which are currently receiving hospice care, with one of these pending discharge from hospice. Residents are observed to be clean and appear well taken care of. Various activities are observed to be provided over the course of the visit. Bathrooms faucets and toilets are operational. Water temperature was verified to be within the required range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted, however the facility is currently using form LIC610D which has been replaced by a new version, which was provided at the conclusion of the visit. Fire drills are conducted quarterly but are not being documented at this time. Smoke and carbon monoxide detectors tested operational. One fire extinguisher present is observed to be fully charged however maintenance is observed to have lapsed in April 2024.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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: GLORIOUS HOME #3
FACILITY NUMBER: 306002818
VISIT DATE: 08/06/2024
NARRATIVE
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CONTINUED FROM FROM LIC809

LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Sharp items, cleaning supplies and medications were confirmed to be inaccessible throughout the physical plant.

The medication central storage was also observed to be secure and was reviewed for accuracy during the visit. During the review, one prescription for one of the admitted residents could not be found in the Medication Administration Records. Caregiving staff confirmed that the prescription was current and not discontinued (as verified on the container's label) and that the medication was currently being administered to the resident even though it had not been added to the records. LPA additionally reviewed five resident files along with five staff files. Some health screening forms and proof of CPR/First aid training were found to be either missing or outdated. Two admission agreements were found to be missing the previous administrator signature.

Based on the observations made during today’s inspection, seven type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. LPA additionally provided a consultation on updates to the Infection Control Plan, Emergency and Disaster Plan as well as staff association requirements in Guardian. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 08/06/2024 05:11 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 08/06/2024 at 04:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #3
FACILITY NUMBER: 306002818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(12)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above as there is not a current Infection Control Plan in place. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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LPA provided licensee with a blank copy of the Infection Control Form. Licensee to complete a provide LPA with a completed copy before the plan of corrections due date.
Type B
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
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Based on records reviewed, the licensee did not comply with the section cited above as three regularly scheduled caregivers had expired CPR training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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Licensee to ensure all staff have received current proof of completion for their CPR training. Documentation to be provided to LPA before the plan of corrections due 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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
Page: 13 of 13
Document Has Been Signed on 08/06/2024 05:11 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 08/06/2024 at 04:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #3
FACILITY NUMBER: 306002818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed during the visit, the licensee did not comply with the section cited above as at least one health screening form was found to be missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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Licensee to ensure all staff have been medically assessed to be in good health and physically/mentallt capacble of performing their duties as documented in the required health screening forms. Documentation to be provided to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, both administrators and one caregivers are confirmed to not yet be associated to the facility at this time. This constitutes a potential risk to the health, safety and personal rights of the individuals in care
POC Due Date: 09/02/2024
Plan of Correction
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Licensee will proceed to request a transfer of background clearance for all three staff members not currently associated before the plan of corrections due 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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 08/06/2024 05:11 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 08/06/2024 at 04:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #3
FACILITY NUMBER: 306002818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review)], the licensee did not comply with the section cited above in as one resident's medication was found to include a current prescription not documented in the medication administration records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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Licensee will audit and review all current medications and ensure Medication Administration Records are current and up-to-date before the plan of corrections due date.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above as three admission agreements are found to either be missing administrator signatures or are using an invlaid template. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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Admission agreements to be updated and provided to LPA before the plan of corrections due 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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2024 05:11 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 08/06/2024 at 04:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #3
FACILITY NUMBER: 306002818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Per CCR 87303(a) "The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the maintenance tag on the mounted fire extinguisher has expired in April 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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Licensee will ensure the fire extinguisher is verified to be operational and will provided documentation to LPA before the plan of corrections due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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