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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003847
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:02:37 PM


Document Has Been Signed on 06/13/2024 01:02 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LG GUEST HOME IIFACILITY NUMBER:
306003847
ADMINISTRATOR:STELLA LADABANFACILITY TYPE:
740
ADDRESS:6700 LASSEN DR.TELEPHONE:
(714) 484-1493
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 3DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Stella LadabanTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit to the facility to complete the required Annual inspection. LPA Haley met with Licensee/Administrator Stella Ladaban and toured the facility.

The facility has a capacity of 6, of which 5 can be non-ambulatory and 1 may be bedridden. The facility phone number 714.484.1493.
Structure: The facility is one level structure with six bedrooms. Currently three bedrooms are being occupied by residents and 1 bedroom is being occupied by staff.
Kitchen: Clean and organized. Sharps locked in a drawer. A perishable food supply was observed in the refrigerator and freezer. Non-perishable food supply was observed in the cabinets and in the pantry near the front door across from the kitchen.
Stove/Appliances: There’s one stove with 4 burners and a warmer, a refrigerator, dishwasher, washer, and dryer. All appliances are clean. The top left burner on the stove does not light unassisted. The washer machine in the garage is not currently working.
Toxins: All cleaning supplies and chemicals are locked under the kitchen sink.
Medications, First-Aid Kit: Resident medications are locked in a close next to the front door. In the locked medication closet, a first aid kit with all the required elements was observed.
Resident & Staff Files: The Resident and Staff Records are kept locked in the closet next to the front door with the medications and the first aid kit.
Bedrooms: Resident bedrooms were clean, organized and were in compliance with regulation guidelines.
Bathrooms: The bathroom has a working toilet, wash basin and shower. Grab bars were tightly secured to the wall.
Hot Water: Hot water was measured at 110.1 degrees F.

Continued on LIC809C
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LG GUEST HOME II
FACILITY NUMBER: 306003847
VISIT DATE: 06/13/2024
NARRATIVE
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Hygiene Supplies: The facility has an adequate supply of hygiene items on hand.
Linens, Hygiene, Emergency Supplies: Additional linens for each resident are stored in the resident closet and dresser drawers. The facility has a large amount of non-perishable food items in the pantry and an emergency water supply in the garage. There are several solar powered lamps and a solar powered radio equipped with a cell phone charger for emergency use and a large supply of batteries in the medication closet.
Emergency Evacuation Drills: The most recent evacuation drill was conducted January 16, 2024. Evacuation drills are conducted quarterly and the evacuation drill for the second quarter will be conducted before the end of the month.
Medication Review: There are currently three residents in the facility and medication was reviewed for all three residents.
Resident File Review: A file review was completed for all three residents.
Staff File Review: 4 staff files were reviewed during the visit.
Garage: The garage is clean and organized, and walk ways were free of obstruction. A washer and dryer was observed. Several cases of water, adult wipes, adult diapers, and several miscellaneous items are being stored in the garage.
Backyard: Clean, organized and walkways are free of obstruction. There was a table with a sunshade and chairs. There is a locked storage shed used to store tools, additional adult diapers, a printer, wood, and gardening items. Both side exit gates are self-closing and self-latching.
Smoke Detectors/Carbon Monoxide Detectors: Smoke detectors and the carbon monoxide detector tested operational. There’s a fully charged fire extinguisher mounted on the wall in the kitchen next to the dining table.
Misc (P&I): N/A. The facility does not manage any of the resident’s money.
Activities, Recreation, Reading Material, etc: Board games, and painting materials were observed in the living room area.
Citation(s) & TV/TA: Citations will be issued for violations of Title 22 regulations observed during todays inspection.
Exit Interview: Exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Stella Ladaban.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2024 01:02 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LG GUEST HOME II
FACILITY NUMBER: 306003847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview confirmation and record review, the licensee did not comply with the section cited above. The facility does not have a current liability insurance policy and the last liability insurance policy on file expired April 18, 2020. This poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Administrator Stella Ladaban will get a current liability insurance policy and email to LPA Haley the certificate of insurance by 1:00pm on or before the POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. During the staff record review several items were missing from the staff files including employee training records. This poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Administrator Stella Ladaban will gather and complete all missing documents for the employee files including employee training records for all staff. The missing documentation will be submitted to LPA Haley by 1:00pm on the 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: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/13/2024 01:02 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LG GUEST HOME II
FACILITY NUMBER: 306003847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being or residents, employees and visitors.

This requirement is not met as evidenced by: The top left burner on the gas stove does not ligh unassisted. The washer in the garage in not working.
Deficient Practice Statement
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Based on observation and interview confirmation, the licensee did not comply with the section cited above. This poses a potential health and safety risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Administrator Stella Ladaban will have the stove and the washer machine repaired or replaced and send proof of the repairs or replacement to LPA Haley by 1:00pm on the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4