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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002871
Report Date: 05/02/2022
Date Signed: 05/02/2022 04:12:14 PM


Document Has Been Signed on 05/02/2022 04:12 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:CONCORDIA GUEST HOME - 3FACILITY NUMBER:
306002871
ADMINISTRATOR:CONCORDIA P. VELASCOFACILITY TYPE:
740
ADDRESS:1065 SAN ANTONIO AVENUETELEPHONE:
(714) 990-5952
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:4CENSUS: 4DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Concordia VelascoTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required - 1 Year evaluation. LPA was greeted and granted entry into the facility by Staff Orlando DeLos Angeles. Licensee/Administrator Concordia Velasco arrived shortly after and explained the reason for the visit. Licensee/Administrator Velasco does not have an active certificate as it expired 2 or 3 years ago.

LPA Martinez toured the facility with Staff DeLos Angeles. Facility has 4 residents in care during today's visit. LPA observed residents in their room taking their afternoon nap. All Residents appeared clean and well taken care of. Facility appears clean and sanitary. Resident rooms had the required elements. Facility does not screen visitors to the facility, but observed the screening/sanitizing station in the facility's entrance. Facility utilizes a hand written visitor sign in sheet. Facility does not monitor resident's and staff temperatures. LPA observed the First Aid kit has all required items. Smoke detectors tested operational during today's visit and Fire Extinguisher were fully charged. LPA observed sufficient supply of emergency food and water as well as emergency supplies. Food supply was sufficient. Toxins are secured. LPA observed a shaded outside visitation area. LPA observed the locked medication area. Facility utilizes a medication administration record. Facility provides activities in the form of exercise and games. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all residents files during the visit and all files have updated emergency information as well as required documents. All resident and staff are vaccinated for COVID-19. LPA consulted with Licensee on the importance of COVID-19 postings throughout the facility as well as screening visitors, residents and staff and documenting.

Based on the observations made during today’s visit the following deficiencies is being cited per Title 22 Division 6 of the California Code of Regulations. This report, along with Appeal Rights, was discussed with the Licensee Velasco and a copy of this report will be emailed on today's date.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 05/02/2022 04:12 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CONCORDIA GUEST HOME - 3
FACILITY NUMBER: 306002871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(c)
Incidental Medical and Dental Care Services. Medications shall be centrally stored if, because of the physical arrangements in the facility and the conditions of other persons in the facility, the medications are determined to be a safety hazard to other residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation Licensee failed to properly lock R2's Insulin Kwik Pens injections in the kitchen refrigerator which poses an immediate risk to the health & safety of residents in care.
POC Due Date: 05/03/2022
Plan of Correction
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Licensee shall ensure that all medication is locked away and made inaccessible to the residents at all times. Should any medication require refrigeration a locked container shall house such medication; Proof of compliance shall be submitted to CCL by 5/3/2022. Will provide in-service training to staff and submit proof of training by 5/10/2022.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/02/2022 04:12 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CONCORDIA GUEST HOME - 3
FACILITY NUMBER: 306002871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(a)
Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Licensee Concordia Velasco, the licensee did not comply with the section cited above. Licensee stated her Administrator Certificate expired 2 or 3 years ago. This poses a potential health and safety risk to persons in care.
POC Due Date: 05/04/2022
Plan of Correction
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Licensee to forward proof of initiating the process to renew Administrator Certificate and/or forward documentation of assigned Administrator to LPA by 5/4/2022.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4