306004054-10-10-2022-22-AS-JCHO-CK3TUH-20221010150222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004054
Report Date: 10/10/2022
Date Signed: 10/10/2022 03:02:32 PM

Document Has Been Signed on 10/10/2022 03:02 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	VICTOR GUEST HOME		FACILITY NUMBER:	306004054
ADMINISTRATOR:	AUGUSTUS A. TORRES		FACILITY TYPE:	740
ADDRESS:	24552 TROY STREET		TELEPHONE:	(949) 215-0619
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 2	DATE:	10/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Lolita Santiago		TIME COMPLETED:	03:20 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	On 10/10/2022 at 1:18pm, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Victor Guest Home. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on Infection Control. At 1:25pm, LPA Cho was greeted and granted entry by Care Staff (CS) Lolita Santiago after completing the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases. Facility screens temperatures for visitors but does not document on a sign in sheet. Per CS Santiago, the facility does not have any visitors. LPA provided guidance to have a sign in sheet in place in the event it is needed. LPA observed temperatures are also taken daily for residents and staff. LPA observed the required COVID-19 precautionary signs posted on the front door. The Complaint Poster (PUB475) met the size requirement. The facility is licensed for six non-ambulatory clients. There are currently two clients living in the facility. One client was at the day program and the second client was at their day job. At 1:29pm, LPA contacted Administrator (Admin) Augustus Torres via a telephone call and stated the purpose of the visit. Admin gave consent to CS Santiago to assist with the tour and sign the report. At 1:32pm, LPA Cho conducted a tour of the physical plant along with CS Lolita Santiago. The single story home consists of four client bedrooms and two client bathrooms. Two of four client bedrooms were vacant. One of two occupied bedrooms was locked. There is one staff private bedroom and bathroom. The facility also has a living room, dining room, kitchen, laundry room, meeting room, and an attached two-car garage. LPA inspected one client bedroom. The client bedroom had the required furnishings. The client bathrooms were checked. The toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Client bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature and the water temperature measured at 106.1 degrees Fahrenheit in the Bathroom #1 and 105.4 degrees Fahrenheit in Bathroom-#2. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

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: VICTOR GUEST HOME	FACILITY NUMBER: 306004054
	VISIT DATE: 10/10/2022

NARRATIVE

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The fire extinguisher was mounted and fully charged. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the clients. LPA Cho toured the outside grounds. No bodies of water was found, and there was shading and sufficient seating for residents in the front yard. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit side gates were self-closing and self-latching. LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility to update the information using the current LIC610E form per the Provider Information Notice (PIN 22-02-ASC) released on 01/06/2022. LPA observed sufficient supply of emergency food/water and PPEs. Backpacks with emergency supplies were mounted on the wall in the dining room.

LPA provided the following guidance: to document visitor's temperatures, to update Emergency and Disaster Plan (LIC610E) using the current form, and to pay the annual licensing fees due on 11/04/2022.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Care Staff Lolita Santiago, and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC809 (FAS) - (06/04)

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