306003594-10-26-2021-22-AS-RQUZ-C86UAR-20211026152509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003594
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:25:16 PM

COMPREHENSIVE INSPECTION

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:	LOIS GUEST HOME II		FACILITY NUMBER:	306003594
ADMINISTRATOR:	MARICEL WRIGHT		FACILITY TYPE:	740
ADDRESS:	17562 MEDFORD AVENUE		TELEPHONE:	(714) 573-7697
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	6	CENSUS: 5	DATE:	10/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Kenneth Forsyth, Administrator		TIME COMPLETED:	03:24 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Caregiver Esther Forsyth and explained the nature of the visit. Upon arrival to the facility, LPA Called and spoke to Licensee/Administrator Louie Dormido via telephone and explained nature of the visit. Administrator (AD) Kenneth Forsyth arrived to facility shortly after and met with LPA Quiroz.

This facility is licensed to provide services to residents age range 60 years and over, 6 Non-Ambulatory Residents and has a hospice waiver for two (2) residents. AD Kenneth Forsyth has an Administrator Certificate with expiration date of 02/15/2023.

On or about 1:22pm LPA Quiroz along with AD Kenneth Forsyth toured the inside and outside of facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed one (1) resident in living-room area resting watching television. Three residents were observed in their bedrooms resting. AD Forsyth indicated R1 is currently not at the facility and is at a Skilled Nursing Facility. Four of five residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. AD Forsyth indicated facility is taking temperatures daily; however not documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment.

CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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: LOIS GUEST HOME II	FACILITY NUMBER: 306003594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2021 Section Cited	1 2 3 4 5 6 7	Care of persons with Dementia 87705(f)(1)(2)(f)The following shall be stored inaccessible to residents with dementia: (1) Knives...other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins...Based on
	8 9 10 11 12 13 14	This requirement was not met as evidenced by:At 1:29pm, LPA Quiroz observed knives drawer next to stove and medication cabinet in kitchen area unlocked. This poses a potential health & safety for residents in care.House Manager and AD Forsyth stated "We forgot to lock it before leaving to lunch."	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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: LOIS GUEST HOME II	FACILITY NUMBER: 306003594
	VISIT DATE: 10/26/2021

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Facility has completed the LIC 808 Mitigation Plan. During today's visit, LPA Quiroz reviewed LIC 808 Mitigation Plan . LIC 808 requiring changes/updates. AD Forsyth agreed to discuss LIC 808 with L/AD Louie Dormido, update and resubmit LIC 808 Mitigation plan to CCL by 10/30/2021.

During today's inspection visit, LPA Quiroz reviewed five of five resident records. AD Forsyth indicated "all residents and staff at facility are fully vaccinated for COVID-19."

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. LIC 9102 Technical Violation was provided during today's visit for COVID-19 guidance. (SEE LIC809-D)

This report was reviewed with Administrator kenneth Forsyth, and a copy of this report, LIC 811, LIC 9102, LIC 809-D and Appeal Rights were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

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