306003594-10-1-2024-22-AS-KLYN-D9MRAS-20241001125136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003594
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:52:55 PM

Document Has Been Signed on 10/01/2024 12:52 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:	10/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Liliosa Manalili and Louie Dormido		TIME COMPLETED:	01:20 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) Kimberly Lyman conducted an unannounced visit to Lois Guest Home II. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 2 residents and the home currently has 2 residents on hospice. Licensee Louie Dormido arrived during the visit. Administrator Ken Forsythe has an administrator certificate valid until 02/15/2025. LPA Lyman along with Caregiver Manalili toured the facility at 9:50 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. The home consists of six resident bedrooms, 2 common restrooms, 1 jack and jill restroom, staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident rooms are single occupancy. 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 119.8 and 130.6 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. At 10:00 AM, LPA observed the wall and doorjamb in the jack and jill restroom is damaged. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the elements including thermometer, tweezers and scissors. LPA observed toxins are secured during today's visit. Kitchen was inspected. LPA observed part of kitchen is being used as storage space with items and debris present. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 10:10 AM, LPA observed multiple expired items in the refrigerator such as salad dressing, cheese and spoiled broccoli. LPA observed two resident's medications unsecured in the refrigerator. Smoke detectors and carbon monoxide detectors tested operational during today's visit. LPA observed two smoke detectors are in need of batteries. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there are no safety concerns noted. Exit gates are unlocked and operational. LPA observed ample emergency food. LPA reviewed the emergency disaster plan and infection control and plans are thorough and complete. CONT ON LIC809-C DATED 10/01/2024

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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: LOIS GUEST HOME II	FACILITY NUMBER: 306003594
	VISIT DATE: 10/01/2024

NARRATIVE

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Facility provided documentation of last fire drill conducted in September 2024. Facility provides activities in the form of exercise, and karaoke. LPA reviewed five resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of medical clearance/ TB, CPR training and criminal record clearance as well as required training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/01/2024 12:52 PM - 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: LOIS GUEST HOME II	FACILITY NUMBER: 306003594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of three water testing. Facility water tested at 127.9 and 130.6 degrees F which poses a potential health, and safety risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee to adjust water temperature and forward proof to LPA by POC due date.

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed kitchen area is being used as storage, the wall in the jack and jill restroom is in need of repair and two smoke detectors are in need of batteries which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee to address noted items and forward proof to LPA by POC due date.

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: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 10/01/2024 12:52 PM - 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: LOIS GUEST HOME II	FACILITY NUMBER: 306003594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed two resident's medications unsecured in the refrigerator (photos) which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/02/2024
	Plan of Correction
1 2 3 4	Licensee to secure noted items and forward proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/01/2024 12:52 PM - 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: LOIS GUEST HOME II	FACILITY NUMBER: 306003594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed multiple expired items as well as soiled broccoli (photos) which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee to forward a statement of understanding of the regulation to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5