306004676-9-15-2022-22-AS-RQUZ-CJAT33-20220915142136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004676
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:21:41 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/15/2022 02:21 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:	SHERCON GUEST HOMES		FACILITY NUMBER:	306004676
ADMINISTRATOR:	CONSOLACION LUMAUIG		FACILITY TYPE:	740
ADDRESS:	13432 GALWAY STREET		TELEPHONE:	(714) 815-9214
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92844
CAPACITY:	6	CENSUS: 5	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:11 PM
MET WITH:	Consolacion Lumauig, Administrator and Edison Sadraca, Administrator Assistant		TIME COMPLETED:	02:34 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection-Infection Control visit. LPA Quiroz was greeted and granted entry into the facility by Licensee/Administrator (L/AD) Consolacion Lumauig and explained the nature of the visit.

This facility is licensed to provide services to residents age range 60 and over, 6 Non-Ambulatory Residents and has a hospice waiver for four (4) residents. Facility is currently providing services to (2) two residents in care. L/AD Consolacion has an Administrator Certificate with expiration date of 08/08/2023.

On or about 12:33pm LPA Quiroz along with (L/AD)Lumauig and Administrator Assistant Edison Sadraca toured the inside and outside of facility. There are five residents in care and there are no active COVID-19 cases at this time. During today's inspection visit, LPA Quiroz observed two (2) residents in dining-room/living room area, and three (3)residents observed resting in their bedrooms. Five of five residents appeared to be clean and well taken care of. LPA Quiroz observed hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water in garage area and limited supply of PPE supplies. (SEE LIC 9102 TV)

During today's visit, LPA Quiroz reviewed 5 of 5 resident records. Resident 5's physician report not available during today's visit (SEE LIC 809-D)

LPA Quiroz along with (L/AD) Lumauig toured the outside of the facility and observed seating shaded area with table and chairs for resident’s enjoyment. Facility has completed the LIC 808 Mitigation plan and infection control plan. CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: SHERCON GUEST HOMES	FACILITY NUMBER: 306004676
	VISIT DATE: 09/15/2022

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During today's inspection visit, LPA Quiroz reviewed five of five resident records. (L/AD) Lumauig indicated 4 of 5 residents and staff are vaccinated and boostered.

During today's visit, water temperature was recorded to be..... degrees Fahrenheit and indoor facility temperature was recorded to be between 77 degrees Fahrenheit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with (L/AD) Consolacion Lumauig, and a copy of this report and LIC 811-Confidential names, LIC 809-D and Appeal Rights were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/15/2022 02:21 PM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHERCON GUEST HOMES	FACILITY NUMBER: 306004676
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2022 Section Cited	1 2 3 4 5 6 7	Medical Assessment 87458(a):(a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year...This requirement was not met as evidence by, During today's visit while LPA Quiroz
	8 9 10 11 12 13 14	reviewed records for R5, LPA Quiroz did not observe physician report for R5. L/AD Lumauig indicated "It's been 2 months and the Family hasn'y brought it." This was verified wtih L/AD Lumauig. This poses a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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