<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004800
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:57:10 PM


Document Has Been Signed on 09/26/2024 04:57 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: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: 5DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Justin MendozaTIME COMPLETED:
05:05 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) Jerome Haley conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry by staff, and explained the reason for the visit before entry. Facility staff called Administrator (AD) Justine Mendoza who arrived with Administrator Cathrine Mendoza and both were present for the remainder of the visit. AD Cathrine Mendoza has a current administrator’s certificate that expires 4/21/26.

At 12:50 PM LPA Haley began the inspection with staff. There were four residents present during the visit. All required postings were observed on the walls throughout the facility.

Right next to the front door there's a half bathroom for staff, residents, and visitors. Next to the bathroom by the front door there's a closet with a supply of nonperishable food items.

Resident rooms and bathrooms were equipped with all the necessary requirements. Hot water temperatures measured in the range of 106.3 – 111.7 degrees Fahrenheit. A supply of additional linen was observed in the hallway closet.

There's an office in between the dining room and living room. Staff and resident files are stored in the locked filing cabinets. A large supply of wound care items and supplies and a first aid kit with all the required elements was observed.

The kitchen was clean and organized. LPA observed a food supply that meets regulation requirements. Licensee was advised on the importance of keeping an adequate food supply and an emergency supply of food items. Medications are kept locked in a cabinet under the kitchen counter along with sharp objects. Hazardous cleaning chemicals are kept locked under the sink.

The garage is used as a storage space. LPA observed mattresses, bed frames, wheelchairs, and walkers. Two additional refrigerators was observed. One for staff food items and one for the resident food supply.

Continued on LIC809C

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 09/26/2024 04:57 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
ORANGE COUNTY RO, 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
A facility shall conduct a drill at least quarterly for each shift. They type of drill shall vary from quarter to quarter... Documentation of the drill shall include the date, the type of emergency covered by the drill, and the names of the staff participating in the drill.

This requirement is not met as evidenced by:
Document review revealed the last emergency evacuation drill was conducted in 2022. LIcensee confirmed no emergency evacuation drill has been conducted.
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses a potential safety rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
1
2
3
4
Licensee stated an emergency evacuation drill will be conducted on or before October 4, 2024. Licensee will email LPA Haley a copy of the emergency evacuation log that documents they type of emergency evacuation conducted and all the participants.
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: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: INTEGRITY GUEST HOME, INC.
FACILITY NUMBER: 306004800
VISIT DATE: 09/26/2024
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
26
27
28
29
30
31
32
A washer and dryer was observed. An emergency supply of water was present.

The backyard was clean, organized, and free of clutter and debris. A shaded area with a table and chairs was observed. A self-latching side exit gate was observed. No bodies of water were observed during today's visit.



There was a charged and mounted fire extinguisher observed in the kitchen. Smoke detectors are battery powered and operate individually. Carbon monoxide detectors tested operational.

During the visit 2 staff interviews were conducted, 2 staff files were reviewed, 5 resident files were reviewed, and 3 resident medications were reviewed.

Deficiencies are being cited and Technical Advisories will be issued as a result of todays visit.

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

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4