306003594-1-31-2023-22-AS-CDPO-CNLRRD-20230131121458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003594
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:15:19 PM

Document Has Been Signed on 01/31/2023 12:15 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:	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:	01/31/2023
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Licensee-Louie Dormido		TIME COMPLETED:	12:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to conduct a case management: health and safety check in this facility. LPA De Perio met with licensee (LE) Louie Dormido stated the purpose of this visit. LPA De Perio conducted a tour of the interior and exterior portions of the facility with LE Dormido and staff on duty. The facility is a single level structure and is licensed for 6 non-ambulatory residents, 60 years and older of which 2 may be on hospice and 0 may be bedridden. Currently, there are a total census of 5 residents in care of which 2 are on hospice. LPA De Perio observed resident bedrooms to be in good repair, and is equipped with clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 108.6 degrees Fahrenheit. Smoke and carbon monoxide detectors were tested and observed to be operational. Auditory alarms were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located on the hallway wall next to the dining area.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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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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: 01/31/2023

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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen.

For this visit, LPA De Perio did not observe immediate threats on the health and safety of residents in care. No citation has been issued at this time.

An exit interview was conducted and a copy of this report was provided to LE Dormido.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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