306003399-3-14-2024-22-AS-JHAY-D3CQND-20240314121859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003399
Report Date: 03/14/2024
Date Signed: 03/14/2024 12:19:11 PM

Document Has Been Signed on 03/14/2024 12:19 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:	QUEEN MARY GUEST HOME II		FACILITY NUMBER:	306003399
ADMINISTRATOR:	EVANGELINE BRUNO		FACILITY TYPE:	740
ADDRESS:	8089 TEAKWOOD CIRCLE		TELEPHONE:	(714) 484-8880
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 5	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Evangeline Bruno - Licensee/Administrator		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Licensee/Administrator (AD) Evangeline Bruno has a current Administrators certificate that expires August 27, 2024.

Queen Mary Guest Home II is a one-story community with 4 bedrooms and two bathrooms. The facility capacity is 6 and the census was 5 during the annual visit. All residents were observed in the living room or in their bedroom during the visit.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had all the requirements and were in compliance with regulation guidelines. Resident bathrooms were in compliance as well. Hazardous cleaning items were locked under the sink and grab bars were tightly secured to the wall. Hot water temperatures were measured in both bathrooms. In bathroom #1 hot water measured at 120.0 degrees Fahrenheit, and in bathroom #2 hot water measured at 118.7 degrees Fahrenheit.

In the hallway, next to bathroom 1, LPA Haley observed cabinets with clean linen. In the hallway there was a locked closet where hazardous cleaning supplies are kept. There was a carbon monoxide detector in the hallway mounted on the wall in between the caregiver room and a resident room.

In the kitchen knives and sharp objects are locked under the sink. There was a perishable food supply that meets the regulation requirements. In the hallway next to the front door there was a supply of non-perishable food items.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUEEN MARY GUEST HOME II	FACILITY NUMBER: 306003399
	VISIT DATE: 03/14/2024

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In the cabinets above the counter, there were locked cabinets with resident medication and first aid supplies that meet regulation requirements. There was a fully charged fire extinguisher in the kitchen and a carbon monoxide doctor mounted on the wall.

The backyard was clean, organized and walkways were free of tripping hazards. There is a small shed with a washer and dryer, a patio area with a table and chairs. The garage is used to store various items. LPA Haley observed facility items like diapers, walkers, bedframes, TVs, and various tool.

Smoke detectors were observed in all resident rooms, the hallway, and living room. All were tested and all were operational. An emergency evacuation drill was conducted January 2, 2024 and the second drill will be conducted soon.

No deficiencies are being cited as a result of today’s visit.

An exit interview conducted and a copy of this report was provided to Licensee/Administrator Evangeline Bruno

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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