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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003397
Report Date: 04/11/2022
Date Signed: 04/11/2022 01:01:13 PM


Document Has Been Signed on 04/11/2022 01:01 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:BELMONT GUESTS RETREAT IFACILITY NUMBER:
306003397
ADMINISTRATOR:ELIZABETH MULLINSFACILITY TYPE:
740
ADDRESS:6541 FAIRLYNN BLVD.TELEPHONE:
(714) 970-0247
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Elizabeth MullinsTIME COMPLETED:
01:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted this unannounced required/annual inspection. LPA was greeted by Administrator (AD) Elizabeth Mullins and discussed the purpose of the inspection. During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

This is a single-story house with six bedrooms and three bathrooms, with one bedroom being occupied by staff. During the inspection, LPA observed there was one staff present with four residents in care. Residents were observed relaxing watching tv in their respective rooms. LPA inspected common areas, resident rooms, kitchen, and garage and observed a 2-day supply of perishables and a 7-day supply of non-perishable food is available. LPA observed hallways and walkways were free of obstruction. Resident files were also review and three of four resident files were found to have incomplete emergency contact information; a deficiency was cited on this day.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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Document Has Been Signed on 04/11/2022 01:01 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: BELMONT GUESTS RETREAT I
FACILITY NUMBER: 306003397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of four resident files which poses a potential health and safety risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Facility needs to update forms and email LPA Claudia Gutierrez copies of the forms completed by 04/15/2022.
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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2