<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003675
Report Date: 07/22/2024
Date Signed: 07/22/2024 10:44:15 AM


Document Has Been Signed on 07/22/2024 10:44 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CHARLOU GUEST HOME IVFACILITY NUMBER:
306003675
ADMINISTRATOR:DOLORES BENEDICTOFACILITY TYPE:
740
ADDRESS:247 S. BRENTWOOD PLACETELEPHONE:
(714) 491-1108
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Dolores Benedicto - LicenseeTIME COMPLETED:
10:58 AM
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) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Dolores Benedicto, Licensee.

The facility is a one-story home with five resident bedrooms, one staff bedroom, one resident bathroom, one staff bathroom, kitchen, dining room, living room, family room, backyard and attached 2-car garage. A section of the home is blocked off from resident access. This part of the home houses family of the Licensee. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for residents in the hallway closet. Restrooms are stocked with soap and paper towels. LPA measured water in resident bathroom to be 110.4 degrees Fahrenheit. LPA noted Fire Extinguishers were last serviced on 06/17/2024 according to the service tag on them. LPA observed the smoke/carbon monoxide detectors to be operational. Facility keeps emergency water and emergency disaster supplies in the garage.

LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a closet in the hallway. The backyard has a shaded sitting/lounging area. Exit gate is unlocked. LPA observed exit gates to be unobstructed. LPA observed a sample menu and activity calendar in the facility. LPA reviewed two of the four resident files and two staff files. LPA also reviewed medication for two out of four residents. LPA interviewed one resident and one staff. Based on record review, LPA determined facility does not have a documented disaster drill log. A deficiency is being issued. Based on record review, LPA advised facility to create a dementia care plan, hospice care plan and bedridden care plan to maintain in the facility plan of operations. LPA issued three Technical Violations (TVs).

One deficiency and three TVs are being issued based on today's inspection. An exit interview was conducted
and a copy of this report and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 07/22/2024 10:44 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CHARLOU GUEST HOME IV
FACILITY NUMBER: 306003675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to being unable to produce documented proof of quarterly disaster drills being conducted at the facility. This poses a potential safety risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
1
2
3
4
Licensee stated they will conduct the next quarterly drill and document it. Licensee also stated they will send documentation to LPA via email by the assigned POC due date of 8/5/2024.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5