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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004250
Report Date: 09/24/2021
Date Signed: 02/22/2022 02:07:26 PM


Document Has Been Signed on 02/22/2022 02:07 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:ESPIRITU GUEST HOME IVFACILITY NUMBER:
306004250
ADMINISTRATOR:CELIA B. MENDOZAFACILITY TYPE:
740
ADDRESS:2602 N. GRAND AVENUETELEPHONE:
(714) 997-9453
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:8CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Celia MendozaTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Neil and Emerson Piscos. Administrator Celia Mendoza was contacted via telephone and she arrived at approximately 12:45pm. Staff were wearing a mask and finishing up dishes from lunch. The focus of the visit was Infection Control. During the visit LPA toured the facility with Neil Piscos and the following was observed:

Covid signage was posted at the front entrance of facility. A sanitization station was set up as you enter the facility. LPA's temperature was taken upon arrival and a sign in sheet was made available. Facility has required Department postings. Administrator Certificate for Celia Mendoza expires on 1/6/23. Rooms were clean and sanitary. All restrooms observed contained paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with shade. Residents were observed watching tv. in their room resting and smoking on the back patio. One resident was at Dialysis. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review Department PINS in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions Entertainment. PIN 21-32 -ASC provides Masking Guidelines.

No citations issued at this time. An exit interview was conducted and copy of this report was provided to Celia Mendoza.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021
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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