306004174-3-12-2025-22-AS-SHAD-DEPT78-20250312142818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004174
Report Date: 03/12/2025
Date Signed: 03/12/2025 02:28:30 PM

Document Has Been Signed on 03/12/2025 02:28 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:	DUELAS GUEST HOME		FACILITY NUMBER:	306004174
ADMINISTRATOR/ DIRECTOR:	LILIA DUELAS		FACILITY TYPE:	735
ADDRESS:	10721 VICKERS DRIVE		TELEPHONE:	(714) 638-8219
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY: 6		CENSUS: 3	DATE:	03/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:23 PM
MET WITH:	Lilia Duelas		TIME VISIT/ INSPECTION COMPLETED:	02:30 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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Lilia Duelas and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 12:45PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 2-bathroom, one-story house with detached garage that is used for storage. There is a back yard with a patio cover for the clients. LPA observed 1 care staff and 1 client present at the facility in addition to AD. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: LPA inspected the one staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 105 degrees F in the client bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 1:30PM, LPA reviewed 3 client files and 3 staff files, interviewed 1 client and 2 staff, inspected medications for 3 clients, and inspected client money and ledgers for 3 clients. CONTINUED

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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 5

Document Has Been Signed on 03/12/2025 02:28 PM - It Cannot Be Edited

Created By: Sean Haddad On 03/12/2025 at 02:01 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DUELAS GUEST HOME	FACILITY NUMBER: 306004174
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the handle on the faucet in the client bathroom was loose which made it impossible to select hot water on the faucet, which poses a potential personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	During the inspection, the licensee fixed the faucet and LPA confirmed. Licensee stated they will retrain staff on fixing broken items in the facility and submit proof to LPA by POC due date.

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents and admission, the administrator has not completed the 3 hour HIV and 1 hour TB training within the last 2 years, which poses a potential health risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee stated they will have the administrator complete the required HIV/TB training and submit proof to LPA by 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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 03/12/2025 02:28 PM - It Cannot Be Edited

Created By: Sean Haddad On 03/12/2025 at 02:01 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DUELAS GUEST HOME	FACILITY NUMBER: 306004174
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

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: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents and admission, the licensee did not ensure 1 out of 3 staff had completed health screenings before working at the facility, which poses a potential health risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee stated they will have all staff health screened and submit proof to LPA by POC due date.

Type B

Section Cited

CCR

80068(a)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not complete admission agreements with 3 out of 3 clients, which poses a potential personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee stated they will complete admission agreements with all 3 clients and submit proof to LPA by 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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 03/12/2025 02:28 PM - It Cannot Be Edited

Created By: Sean Haddad On 03/12/2025 at 02:01 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DUELAS GUEST HOME	FACILITY NUMBER: 306004174
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(b)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents and observation, the licensee did not administer 1 dose of 400MG Magnesium Oxide to Client #1 (C1), which poses a potential health risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee stated they will notify C1's doctor, conduct training on medication administration, and submit proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: DUELAS GUEST HOME	FACILITY NUMBER: 306004174
	VISIT DATE: 03/12/2025

NARRATIVE

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During the inspection, LPA and AD observed the following: based on observation, the handle on the faucet in the client bathroom was loose which made it impossible to select hot water on the faucet; based on documents and admission, the administrator has not completed the 3 hour HIV and 1 hour TB training within the last 2 years; based on documents and admission, the licensee did not ensure 1 out of 3 staff had completed health screenings before working at the facility; based on documents, the licensee did not complete admission agreements with 3 out of 3 clients; and based on documents and observation, the licensee did not administer 1 dose of 400MG Magnesium Oxide to Client #1 (C1).

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

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