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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004697
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:16:06 PM

Document Has Been Signed on 11/14/2024 04:16 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:LEISURE TOWER GUEST HOME LLCFACILITY NUMBER:
306004697
ADMINISTRATOR/
DIRECTOR:		KEITH SWAYNEFACILITY TYPE:
735
ADDRESS:1305 EAST CHAPMANTELEPHONE:
(714) 538-2054
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY: 40CENSUS: 39DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Keith Swayne-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:32 PM
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Brandon Lopez conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Administrator (AD) Keith Swayne.

LPAs observed the Administrator's Certificate for facility AD Keith Swayne which expires on August 07, 2025.

LPAs and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and storage areas and observed the following: Structure: facility is a large complex composed of a large two-story home, a two-story back house, and a one-story side house with multiple rooms and multiple bathrooms. There is a back yard with a patio cover for the clients. LPAs observed two staff and multiple clients present at the facility. Client Bedrooms: the ten client bedrooms inspected are spacious and will easily accommodate the clients’ furnishings. Furniture for ten client bedrooms inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: temperature was tested at random bathrooms and it tested between 105.7-108.2 degrees Fahrenheit. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed in a closet by the Medication room. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs 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 and Smoke Detectors were tested and operational. Fire Extinguishers were mounted throughout the facility with a service tag dated November, 13, 2023. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the Medication room. Toxins: observed locked in the basement. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPAs reviewed five client files and two staff file. LPAs observed that four of five client records reviewed do not have an Appraisal & Needs Service Plan; a Deficiency was issued today. LPAs observed that four of five client records reviewed do not have a Physician Report (LIC602)/medical assessment; a Deficiency was issued today.



CONTINUED...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: LEISURE TOWER GUEST HOME LLC
FACILITY NUMBER: 306004697
VISIT DATE: 11/14/2024
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For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPAs advised AD Swayne to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPAs conducted an exit interview with AD Swayne and a copy of this report and Appeal Rights were provided to the AD.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 04:16 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 11/14/2024 at 03:20 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: LEISURE TOWER GUEST HOME LLC
FACILITY NUMBER: 306004697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that four of five client records reviewed do not have an Appraisal & Needs Service Plan.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee to complete a written Needs and Services Plan for Client 1 (C1) , C2, C3 and C4. Licensee to email proof to LPA by POC due date.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that four of five client records reviewed do not have a Physician Report (LIC602)/medical assessement.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee to complete a Physican Report (LIC602)/medical assessment for Client 1 (C1) , C2, C3 and C4. Licensee to email 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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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