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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004800
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:01:00 PM

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:INTEGRITY GUEST HOME, INC.FACILITY NUMBER:
306004800
ADMINISTRATOR:CATHERINE MENDOZAFACILITY TYPE:
740
ADDRESS:6576 CHRISTINE CIRCLETELEPHONE:
(714) 995-3603
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 4DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Hospesio Alcover and Catherine MendozaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Hospesio Alcover and explained the reason for the visit. Administrator Catherine Mendoza arrived during the visit. Administrator Catherine Mendoza has an administrator certificate expiring on 04/21/2022.

At 1:25 PM, LPA toured the facility with Administrator Mendoza. Facility has 4 residents in care during today's visit, with one on hospice care. LPA observed residents relaxing in the facility. All residents appeared well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility. Facility does not currently utilize a visitor sign in sheet. Facility takes resident and staff temperatures daily. LPA observed the first aid kit has all required items. Facility mitigation plan has been submitted and is pending approval. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked and self latching. LPA observed the locked medication area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. All residents and staff are vaccinated from Covid-19. LPA reviewed all resident files during the visit and all include updated emergency information.

LPA consulted with Administrator regarding the importance of documenting visitor symptom status and temperatures taken as well as having Covid precaution signage inside and outside the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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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