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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003675
Report Date: 07/18/2022
Date Signed: 07/18/2022 11:59:17 AM


Document Has Been Signed on 07/18/2022 11:59 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
CCLD Regional Office, 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: 4DATE:
07/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Facility Administrator - Elizabeth Lutz TIME COMPLETED:
12:17 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty (S1). During the visit, 2 staff were on duty, who contacted facility administrator (AD) Elizabeth Lutz about visit. As of 7/18/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB 475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA observed the Administrator's Certificate for Elizabeth F. Lutz, which expires on 7/26/22 and payment for renewal was submitted on 4/28/22.

LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 residents, of which 6 are non-ambulatory and a hospice waiver for 3. Currently, there are a total of 4 residents in care, of which 2 are on hospice. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 111.9 degrees Fahrenheit. Hand-washing signs were also observed to be posted in each restroom.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
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: CHARLOU GUEST HOME IV
FACILITY NUMBER: 306003675
VISIT DATE: 07/18/2022
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Fire extinguisher was charged, mounted and located in the kitchen. For the exterior portion, LPA De Perio observed seating area under shading, and the grounds were free of any hazards. There are two gates in the backyard, both which were self-closing and self-latching. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance of the facility. Facility had back-up emergency food and water supply, located in the garage.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in a cabinet located in the hallway. Toxins were also observed to be locked and inaccessible to residents.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Lutz. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio conducted an exit interview with AD Lutz and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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