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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003507
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:06:42 AM


Document Has Been Signed on 10/25/2023 11:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ADELINE'S GUEST HOMEFACILITY NUMBER:
306003507
ADMINISTRATOR:ADELINE V. MONCERAFACILITY TYPE:
740
ADDRESS:2108 CARLETON CIRCLETELEPHONE:
(714) 504-0697
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 2DATE:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Araceli LeeTIME COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Araceli Lee. LPA discussed the purpose of the inspection and was informed by Staff Lee that Administrator (AD) Adeline Moncerna was away on a trip and would not be available for today's inspection.

During the inspection LPA and Staff Lee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a two-story house with three bedrooms, and two bathrooms on the first floor. The second story consists of two bedrooms and one bathroom and is utilized as staff quarters. Facility currently has a census of two. LPA observed one resident waiting to be picked up for day program. Per staff, the second resident had already been picked up for their day program. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The back yard and front courtyard have a shaded sitting area. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. A disaster drill log was not available for review and staff present was unable to confirm the frequency of drills conducted; a deficiency was cited on today's date. Appliances were all inspected. Sharps were observed locked in a kitchen cabinet. Medication cabinet was observed to be locked. LPA reviewed two out of two resident files and two staff files. LPA observed AD does not have a current, unexpired AD certificate, and staff present was unable to confirm if AD had renewed their certificate or competed certification requirements; a deficiency was cited on this day. LPA interviewed staff and client present. (Cont. LIC809-C)
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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 10/25/2023 11:06 AM - 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: ADELINE'S GUEST HOME
FACILITY NUMBER: 306003507

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview, and record review, the licensee did not comply with the section cited above as LPA observed AD does not have a current, unexpired AD certificate, and staff present was unable to confirm if AD had renewed their certificate or competed certification requirements which poses a potential personal rights risk to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Staff Lee stated AD will provide LPA with copies of documentation that AD has met certification requirements via email by POC date.
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
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Based on staff interview, the licensee did not comply with the section cited above as a disaster drill log was not available for review, and staff present was unable to confirm the frequency of drills conducted which poses a potential safety risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Staff Lee stated AD will provide LPA with documentation of drills conducted which include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This documentation will be maintained and will be available upon request.
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 LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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: ADELINE'S GUEST HOME
FACILITY NUMBER: 306003507
VISIT DATE: 10/25/2023
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Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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