306002871-6-4-2025-22-AS-EKIM-DHBVU8-20250604164418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002871
Report Date: 06/04/2025
Date Signed: 06/04/2025 04:44:38 PM

Document Has Been Signed on 06/04/2025 04:44 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:	CONCORDIA GUEST HOME - 3		FACILITY NUMBER:	306002871
ADMINISTRATOR/ DIRECTOR:	MICHAEL O. ROACH		FACILITY TYPE:	740
ADDRESS:	1065 SAN ANTONIO AVENUE		TELEPHONE:	(714) 990-5952
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	06/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Caregiver Orlando Delos Angeles		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 June 4, 2025 at 1:15 PM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Orlando Delos Angeles. Licensee (LI) Concordia Velasco was contacted over the phone and LPA explained the purpose of the visit. LI Velasco arrived around 1:50 PM and left around 3:20PM. LI Velasco stated that CG Delos Angeles could sign in behalf of the facility. The facility is licensed to operate for four (4) non-ambulatory and have a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: Three (3) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, and an outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant with LI Velasco. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 109.7 and 109.9 degrees F. A comfortable temperature of 76 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: CONCORDIA GUEST HOME - 3	FACILITY NUMBER: 306002871
	VISIT DATE: 06/04/2025

NARRATIVE

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LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. LPA Kim observed emergency food and water are stored in the pantry next to the facility entrance. The facility has smoke detectors and carbon monoxide detectors that were operable. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). A working telephone (714-990-5952) remains available. First Aid Kit contained all the necessary elements.

LPA conducted an audit of all resident files (R1-R4), all staff files (S1-S2), and medication and medication administration record. LPA Kim conducted two (2) resident interviews and one (1) staff interview.

Deficiencies were cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). LPA observed a bottle of Cascade and a bottle of Finish Jet dry in an unlocked cabinet under the kitchen sink. LPA observed S1 did not have a valid CPR/First Aid certificate, and the PUB475 See Something Say Something measured at 10.5” x14.5” instead of the 20" x 26" requirement.

An exit interview was conducted and a copy of this report and appeal rights were provided to Caregiver Orlando DeLos Angeles.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/04/2025 04:44 PM - It Cannot Be Edited

Created By: Edward Kim On 06/04/2025 at 04:00 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: CONCORDIA GUEST HOME - 3	FACILITY NUMBER: 306002871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above. LPA observed a bottle of Cascade and a bottle of Finish Jet Dry were left in an unlocked cabinent under the kitchen sink.This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2025
	Plan of Correction
1 2 3 4	Facility immediately placed the bottle of Cascade and bottle of Finish Jet Dry in a locked cabinet in the garage.

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.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (916) 956-7332

	Edward Kim
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (714) 293-1237

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/04/2025 04:44 PM - It Cannot Be Edited

Created By: Edward Kim On 06/04/2025 at 04:00 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: CONCORDIA GUEST HOME - 3	FACILITY NUMBER: 306002871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed S1 did not have a valid CPR/First Aid certificate. The last CPR expired on May 4, 2025. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee states they will have S1 have a current and valid CPR training certificate and send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date June 18, 2025.

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) .... A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed a framed PUB475 See Something Say Something paper measured at 10.5" x 14.5" instead of the 20" x 26" requirement. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee states they will provide the PUB475 20" x 26" See Something Sy Something poster and posted in the main entryway by submitting proof of completion to CCLD via email to edward.kim@dss.ca.gov by POC due date June 18, 2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (916) 956-7332

	Edward Kim
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (714) 293-1237

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC809 (FAS) - (06/04)

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