306004800-8-12-2022-22-AS-JHAY-CH8SRM-20220812140633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004800
Report Date: 08/12/2022
Date Signed: 08/12/2022 02:06:52 PM

Document Has Been Signed on 08/12/2022 02:06 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:	INTEGRITY GUEST HOME, INC.		FACILITY NUMBER:	306004800
ADMINISTRATOR:	CATHERINE MENDOZA		FACILITY TYPE:	740
ADDRESS:	6576 CHRISTINE CIRCLE		TELEPHONE:	(714) 995-3603
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 4	DATE:	08/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Aquilo Alcover		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff, and explained the reason for the visit. Facility staff called Administrator (AD) Catherine Mendoza who was unavailable. Staff then called Justine Mendoza who arrived at the end of the inspection. AD Mendoza has a current administrators certificate that expires 4/21/24.

At 11:40 AM LPA Haley began the inspection with staff. There were four residents present during todays visit. A screening station was observed near the front door. LPA Haley was temperature checked before entering the facility. Right next to the front door there's a half bathroom for visitors. Next to the bathroom by the front door there's a closet with a supply of non perishable items. All required postings were observed on the walls through out the facility.

Resident rooms and bathrooms were equipped with all the necessary requirements. Hot water temperatures measured at 106.1 degrees Fahrenheit in bathroom #1 and 105.9 degrees Fahrenheit in bathroom #2. Plenty of extra linen was observed in the hallway closet.

There's an office in between the dining room and living room. In the office LPA Haley observed a closet with a adequate supply of PPE and a first aid kit.

The garage is used as a storage space. LPA observed mattresses, bed frames, wheelchairs, and walkers. A walk way clear and clutter and tripping hazards was observed. In the garage LPA Haley observed a cabinet with cleaning supplies, a washer and dryer, and a refrigerator with some perishable food items present. An emergency supply of water was observed in the garage.

The back yard was clean and free of clutter and debris. A shaded area with tables and chairs was observed. The side exit gate was self closing and self latching.

Continued on LIC 809 C Dated 8/12/22

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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: INTEGRITY GUEST HOME, INC.	FACILITY NUMBER: 306004800
	VISIT DATE: 08/12/2022

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In the kitchen knives and sharp objects are stored under the kitchen sink. All four burners on the stove were operational. LPA observed a 2 day supply of perishable items and a 7 day supply of non perishable items. There was a charged and mounted fire extinguisher observed in the kitchen.

Smoke detectors battery powered and individually operating. Seven smoke detectors were operational. In the hallway one smoke detector was tested and observed to be non operational.

No bodies of water were observed during today's visit.

Deficiencies are being cited per California Code of Regulations Title 22 Division 6 Chapter 8, and a technical advisory will be issued during todays visit.

An exit interview was conducted and a copy of the report and appeal rights were left at the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2022 02:06 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: INTEGRITY GUEST HOME, INC.	FACILITY NUMBER: 306004800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of several broken and missing blinds in resident room and living room and interview confirmation from staff during the inspection, the licensee did not comply with the section cited above which poses a potential health, or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	Licensee will replace the broken/missing blinds or hang up curtains on the windows.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC809 (FAS) - (06/04)

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