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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004073
Report Date: 11/27/2024
Date Signed: 11/27/2024 09:58:41 AM

Document Has Been Signed on 11/27/2024 09:58 AM - 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:MISSY'S GUEST HOMESFACILITY NUMBER:
306004073
ADMINISTRATOR/
DIRECTOR:		RODOLFO G. MENDOZAFACILITY TYPE:
740
ADDRESS:9131 HEALEY DRIVETELEPHONE:
(714) 530-4421
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Rodolfo MendozaTIME VISIT/
INSPECTION COMPLETED:
11:14 AM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin made an unannounced required annual inspection in this facility. LPA was granted entry and met with administrator (AD) Rodolfo Mendoza and explained the purpose of the visit.

The facility is a single level structure with 5 bedrooms in which 4 bedroom designated for residents in care. The facility is licensed for six non-ambulatory with a hospice waiver for two. This facility is a Residential Care Facility for the Elderly/Hospice.

LPA toured the interior and exterior portions of the facility. Resident rooms were provided with furniture, chair, clean linen, adequate storage space, and kept free of tripping hazards. Hard wired smoke detectors, carbon monoxide and audible exit alarms were tested to be operational. LPA observed all required posting to be hung and in the right size. LPA observed emergency drill documented for July/4/2024 and scheduled drill for 11/29/2024. All files of staff and clients contained all required documentation.

LPA checked the kitchen and observed an unlocked cabinet which stored chemicals was accessible to residents in care. AD immediately locked the cabinet.

Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 116.9 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements.

For the exterior portion, facility had a shaded area and chairs; grounds were clear of tripping hazards and space for activities. Facility has a 2-car garage and is kept locked and used for storage; the garage also had an operational washer and dryer.

Based on the observation made today, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096
DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/27/2024 09:58 AM - 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: MISSY'S GUEST HOMES
FACILITY NUMBER: 306004073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in leavining chemicals in unlocked cabinet which poses an immediate health, safetyto persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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AD will conduct training to staff and E mail training to LPA by 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.
Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096

DATE: 11/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2024

LIC809 (FAS) - (06/04)
Page: 2 of 2