306003048-11-22-2023-22-AS-DLMN-CXTU6M-20231122141835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003048
Report Date: 11/22/2023
Date Signed: 11/22/2023 02:20:30 PM

Document Has Been Signed on 11/22/2023 02:20 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	HELEN'S GUEST HOME		FACILITY NUMBER:	306003048
ADMINISTRATOR:	LIBERTY VENTURA		FACILITY TYPE:	740
ADDRESS:	9152 HYDE PARK DRIVE		TELEPHONE:	(714) 378-0970
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92646
CAPACITY:	4	CENSUS:	DATE:	11/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:			TIME COMPLETED:	02:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry by DSP Imelda Delrosario. Facility Manager Sarah Levante joined the inspection during the tour.

The facility is a one-story home with four resident bedrooms, two bathrooms, kitchen, dining room, living room, laundry room, staff office, back yard and attached two-car garage. Facility appeared clean, sanitary and well-organized. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels. Hot water measured at 105 degrees Fahrenheit in both bathrooms. LPA issued a technical assistance requesting that the staff closely monitor the water temperatures to remain in compliance and obtain a new water thermometer. LPA observed exit gates in the backyard to be operational and unobstructed. Facility has three shaded seating areas in the backyard. Smoke and Carbon Monoxide detectors tested operational. LPA observed facility has emergency food and water supply. Laundry machines are operational. Facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food. Fire Extinguisher was observed to be fully charged as indicated by the built-in meter. The service tag indicates it was last serviced on 10/31/23. LPA reviewed medication and files for all four clients. Facility manages money for two of their residents. LPA reviewed P&I with Facility Manager. The P&I appeared accurate after the Facility Manager updated the ledger for one client. LPA used the ledger’s history to verify the validity of the Facility Manager’s update. A Technical Assistance was issued regarding P&I. LPA reviewed five staff files. LPA observed two out the five files had current First-Aid/CPR certificates, the other three did not. Facility Manager stated they will have staff complete First-Aid/CPR training. A Technical Violation was issued. LPA observed the disaster drill records, which indicate the last time a drill was completed was in May of 2023. A deficiency is being issued on this day.

Based on today’s inspection, one deficiency one technical violation and two technical assistances were issued. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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 11/22/2023 02:20 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HELEN'S GUEST HOME	FACILITY NUMBER: 306003048
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as their last recorded disaster drill occured in May of 2023. This poses a potential safety risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Facility Manager stated facility will conduct a disaster drill, document it on their disaster drill log, scan it and send it to the LPA via email by the assigned POC due date of 12/06/2023.

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: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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