306003954-6-16-2022-22-AS-ETAA-CFFTAC-20220616143320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003954
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:33:33 PM

Document Has Been Signed on 06/16/2022 02:33 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:	PILGRIMS GUEST HOME		FACILITY NUMBER:	306003954
ADMINISTRATOR:	NORMITA/JOSE VIBAR		FACILITY TYPE:	740
ADDRESS:	8431 SANTA BERTA WAY		TELEPHONE:	(714) 995-4020
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 5	DATE:	06/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Dolores Milco, Normita Vibar, Jose Vibar		TIME COMPLETED:	02:40 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 required annual inspection at this facility. LPA met with staff Dolores Milco and stated the purpose of this visit. Administrator Normita Vibar and Jose Vibar arrived during the inspection to provide assistance. The facility is a single level structure and licensed for six non-ambulatory up to six can be developmentally disabled of which one can be on hospice. This facility offers Residential Care for the Elderly. At about 12:50 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed two clients in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. One room was for staff only. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 107.2 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 106.3 degrees Fahrenheit. 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 residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed to be charged and operational. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA observed a hand shovel outside and staff immediately removed and locked up equipment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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: PILGRIMS GUEST HOME	FACILITY NUMBER: 306003954
	VISIT DATE: 06/16/2022

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Facility also had a 2 car garage which is used for storage and emergency supplies. Kitchen was in good repair with knifes and cleaning supplies kept locked. LPA noticed some of the emergency food supplies were expired and informed Administrator. LPA also noticed a cockroach while inspecting the kitchen. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA 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. Two advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Normita Vibar and copy of this report was explained and 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: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC809 (FAS) - (06/04)

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