306004250-9-30-2022-22-AS-JCHO-CJRTTV-20220930150121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004250
Report Date: 09/30/2022
Date Signed: 09/30/2022 03:01:28 PM

Document Has Been Signed on 09/30/2022 03:01 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 IV		FACILITY NUMBER:	306004250
ADMINISTRATOR:	CELIA B. MENDOZA		FACILITY TYPE:	740
ADDRESS:	2602 N. GRAND AVENUE		TELEPHONE:	(714) 997-9453
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	8	CENSUS: 4	DATE:	09/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Roy Borja		TIME COMPLETED:	03:15 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 09/30/2022 at 1:35pm, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Espiritu Guest Home IV. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 1:43pm, LPA Cho was greeted and allowed entry by Care Staff Nilo Piscos after completing the Coronavirus 2019 (COVID-19) screening procedure. Staff Emerson Piscos was present at the facility and Lead Staff Flora Piscos and Licensee Roy Borja arrived at the facility around 2:03pm. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted throughout the facility. The Complaint Poster (PUB475) did not meet the size regulation of 20"x26." The facility is licensed for eight non-ambulatory residents and has a hospice waiver for two. There are currently four residents living in the facility of which one is receiving hospice care. The Administrator's Certificate for Celia Mendoza expires on 01/06/2023. At 1:58pm, LPA Cho conducted a tour of the physical plant along with Care Staff Emerson Piscos. The single story home consists of four resident bedrooms and three resident bathrooms. There are two staff bedrooms. The facility also has a living room, dining area, kitchen, office area, laundry room, and a frront/back patio. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident 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 in the resident bathrooms and the temperature measured at 114.2 degrees Fahrenheit in the Bathrooms #1, #2, and 113.1 degrees Fahrenheit in Bathroom #3.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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: ESPIRITU GUEST HOME IV	FACILITY NUMBER: 306004250
	VISIT DATE: 09/30/2022

NARRATIVE

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LPA Cho inspected the kitchen along with Staff Emerson. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged and purchased on 03/17/2022. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds with Staff Emerson and Flora. There were no bodies of water present. There was shading and sufficient seating for residents. 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 Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components, and the facility had sufficient PPEs. The facility did not have the Infection Control Plan. Licensee Roy Borja acknowledged and agreed to submit the Infection Control Plan (LIC9282) and the Emergency Infection Control Plan pertaining to the Monkeypox guidelines by 10/14/2022. LPA discussed the Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides a laptop upon request.

LPA provided the following guidance: to enlarge the PUB475 in the required sizing of 20"x26" and to complete and submit the LIC9282 and the Monkeypox addendum by 10/14/2022. LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

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 (LIC9102s) were issued during the visit. An exit interview was conducted with Licensee Roy Borja, 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: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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