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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003397
Report Date: 02/07/2025
Date Signed: 02/07/2025 11:14:35 AM

Document Has Been Signed on 02/07/2025 11:14 AM - 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:BELMONT GUESTS RETREAT IFACILITY NUMBER:
306003397
ADMINISTRATOR/
DIRECTOR:
ELIZABETH MULLINSFACILITY TYPE:
740
ADDRESS:6541 FAIRLYNN BLVD.TELEPHONE:
(714) 970-0247
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Administrator- Elizabeth MullinsTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On February 7, 2025, at 8:20am, 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 Administrator (AD) Elizabeth Mullins. LPA Kim explained the purpose of the visit to AD Mullins.

The facility is licensed to operate for six (6) nonambulatory residents, of which 1 may be bedridden, and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: one (1) staff bedroom, five (5) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with AD Mullins. There were no bodies of water or obstructions in the facility. 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. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 110.3 degrees F to 114.4 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility.

LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, 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 both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage.

Evaluation Report Continues on LIC 809-C

Lourdes MontoyaTELEPHONE: (916) 956-7332
Edward KimTELEPHONE: (714) 293-1237
DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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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: BELMONT GUESTS RETREAT I
FACILITY NUMBER: 306003397
VISIT DATE: 02/07/2025
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) in the shed in the backyard. All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-970-0247) and video teleconferencing mobile telephone dedicated to the residents both remain available. Last emergency drill was conducted on December 30, 2024, and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. The facility has two (2) fire extinguisher that are charged and mounted in the resident hallway.

LPA Kim conducted an audit of resident files (R1-R2), staff files (S1-S5), and medication and medication administration record were in all in order and complete. LPA Kim conducted two (2) staff interviews.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Elizabeth Mullins.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
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