306003847-5-31-2022-22-AS-ETAA-CEXVZZ-20220531165334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003847
Report Date: 05/31/2022
Date Signed: 05/31/2022 04:53:49 PM

Document Has Been Signed on 05/31/2022 04:53 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:	LG GUEST HOME II		FACILITY NUMBER:	306003847
ADMINISTRATOR:	STELLA LADABAN		FACILITY TYPE:	740
ADDRESS:	6700 LASSEN DR.		TELEPHONE:	(714) 484-1493
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 3	DATE:	05/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:51 PM
MET WITH:	Stella Ladaban		TIME COMPLETED:	05:00 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) Edward Tapia made an unannounced annual inspection at this facility. LPA met with Administrator Stella Ladaban and stated the purpose of this visit. The facility is a single level structure and licensed for five non-ambulatory one of which may be bedridden three are non-ambulatory. This facility is a Residential Care Facility for the Elderly. About 2:51 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed three clients in care and one staff member on the duty. LPA toured the interior and exterior portions of the facility. There was one shared client room, One client private room and one client empty room. There were three private staff rooms with three private restrooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. LPA noticed auditory exit alarms did not operate and Administrator will fix immediately. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 105 degrees Fahrenheit. LPA did notice a toxin in the bathroom and was immediately removed and made inaccessible to residents. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was on observed but was not current. LPA made Administrator aware and Administrator will replace immediately. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. A ladder was observed and removed so residents could not access it. LPA LPA did notice a portion of the pavement was uneven. Administrator will have floor even using a piece of wood or floor mat.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: LG GUEST HOME II	FACILITY NUMBER: 306003847
	VISIT DATE: 05/31/2022

NARRATIVE

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Garage is kept locked and used for storage and an office for one of the staff. Garage also has an operating washer/dryer. Kitchen was in good repair with medications kept locked. LPA noticed first aid kit did not have an operation manual. Administrator was made aware and with have one immediately. LPA notice PUB 475 poster was not posted near entrance of facility. LPA informed Administrator PUB 475 needs to be posted at all times in 20 x 26 inches. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPAs discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to 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 this visit, no deficiency was noted in areas observed. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Stella Ladaban and copy of this report was left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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