306004399-3-23-2024-22-AS-CDPO-D3N24H-20240323170358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004399
Report Date: 03/23/2024
Date Signed: 03/23/2024 05:04:26 PM

Document Has Been Signed on 03/23/2024 05:04 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	QUALITY SENIOR LIVING		FACILITY NUMBER:	306004399
ADMINISTRATOR:	MARIA DOLORES D TENTE		FACILITY TYPE:	740
ADDRESS:	24262 GRASS STREET		TELEPHONE:	(949) 215-3087
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	03/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Felijun Casuyon - House Manager		TIME COMPLETED:	03:45 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) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by house manager (HM) Felijun Casuyon. LPA observed the administrator certificate for Maria Tente, which expires on 12/3/2024. The PUB475 "See Something, Say Something" poster was also observed to be posted at the entrance. Facility is licensed for 6 non-ambulatory residents, of which 2 may be on hospice. During this visit, there are a total of 5 residents in care, of which 2 are on hospice and 2 staff on duty. LPA De Perio toured the interior and exterior portions of the facility with HM Cauyon. The facility is a two level structure. On the first floor, there are a total of 5 bedrooms, of which 4 are private resident rooms, and 1 shared resident room. On the second floor, there are a total of 3 bedrooms, of which are only for staff. During this visit, LPA observed and verified that there are no residents residing on the second floor. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. On the first floor, there are a total of 4 bathrooms for residents, and 1 bathroom on the second floor for staff. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 107.7 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the living room. Facility had back-up emergency food and water supply, located in the kitchen and in the garage.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY SENIOR LIVING	FACILITY NUMBER: 306004399
	VISIT DATE: 03/23/2024

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LPA De Perio observed that First Aid Kit had all the required components. Medications and toxins were observed to be locked and made inaccessible to residents in care.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with HM Casuyon.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2024

LIC809 (FAS) - (06/04)

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