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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003515
Report Date: 02/19/2025
Date Signed: 02/19/2025 11:44:49 AM

Document Has Been Signed on 02/19/2025 11:44 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:MARY'S ASSISTED HOME LIVINGFACILITY NUMBER:
306003515
ADMINISTRATOR/
DIRECTOR:		MAUREEN SALONGAFACILITY TYPE:
740
ADDRESS:11642 DALE STREETTELEPHONE:
(714) 537-0899
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Evangeline GalvezTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregivers, Flordeliza Balabbo and Remedios De Leon Marquez and explained the reason for the visit. Licensee (LE) Evangeline Galvez arrived shortly to help assist with the visit. Facility is licensed for six non-ambulatory residents, with a hospice waiver for three. Currently there are four residents, of which two are on hospice during today's visit.

Around 8:30 AM LPA reviewed four resident files and two staff files. Residents files and staff files contained all required documentation. Administrator certificate expires on July 4, 2025.



LPA Tea along with LE Galvez toured the facility at 9:23 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of four resident bedrooms, three full bathrooms, living room, dining and kitchen area, and a caregiver area. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106.5 F degrees to 108.8 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen cabinet. LPA also observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink. Fire extinguishers throughout the facility were fully charged. Kitchen appliances are operational during today's visit.

Annual Report continuation on LIC 809-C
Alisa OrtizTELEPHONE: (714) 287-4084
Michael TeaTELEPHONE: 714-703-2840
DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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Document Has Been Signed on 02/19/2025 11:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MARY'S ASSISTED HOME LIVING
FACILITY NUMBER: 306003515

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA's review of facility records, licensee said they did do disaster drills and record them. LPA asked for the records and the licensee could not find them. This poses as a potential health and safety risk to residents in care.
POC Due Date: 03/05/2025
Plan of Correction
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Provide proof of disaster drill logs to LPA by POC due date.
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.
Alisa OrtizTELEPHONE: (714) 287-4084
Michael TeaTELEPHONE: 714-703-2840

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025

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: MARY'S ASSISTED HOME LIVING
FACILITY NUMBER: 306003515
VISIT DATE: 02/19/2025
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LPA toured the outside grounds and there is ample seating with shade and one exit gate on the right side of the facility is self latching and operational. LPA observed emergency food and water supply. LPA Tea observed residents watching television, eating lunch and relaxing in their room. Activities for the resident's are limited due to the resident's physical condition, but sometimes the staff takes them out for a walk if they are able to.

At 9:40 AM LPA reviewed medication storage and administration. Medications are stored in a locked closet by the living room. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Licensee Evangeline Galvez and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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