306004073-7-20-2022-22-AS-ETAA-CGHU8L-20220720152142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004073
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:21:53 PM

Document Has Been Signed on 07/20/2022 03:21 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:	MISSY'S GUEST HOMES		FACILITY NUMBER:	306004073
ADMINISTRATOR:	RODOLFO G. MENDOZA		FACILITY TYPE:	740
ADDRESS:	9131 HEALEY DRIVE		TELEPHONE:	(714) 530-4421
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Maria Mendoza, Rodoflo Mendoza		TIME COMPLETED:	03:35 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 in this facility. LPA met with Licensee Maria Mendoza and stated the purpose of this visit. Administrator Rodolfo Mendoza arrived during the visit and provided assistance. The facility is a single level structure and licensed for six non-ambulatory with a hospice waiver for two. This facility is a Residential Care Facility for the Elderly/Hospice. At about 1:10 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed five residents in care and one staff member on duty. LPA noticed Caregiver Elizabeth Caburnay not associated at the facility. Administrator provided LIC 9182 and DOJ criminal background check. LPA was given a copy and will not issue a civil penalty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms, 2 of which are shared rooms. 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 121.4 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 122.9 degrees Fahrenheit. Administrator was made aware of the water temperature regulations. 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 on observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA did notice gardening hose was untangled. Administrator immediately removed item so residents could not access it. LPA also noticed a spring for the back door leading to the front of the home needed to be fixed. Administrator immediately fixed spring. Garage is kept locked and used for storage and with two emergency washers and dryers.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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: MISSY'S GUEST HOMES	FACILITY NUMBER: 306004073
	VISIT DATE: 07/20/2022

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Garage also contains emergency supplies. Kitchen was in good repair with medications kept locked separately. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster 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. One advisory and no violation was issued today.

LPA Tapia conducted an exit interview with Administrator Rodolfo Mendoza 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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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