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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005247
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:31:19 PM


Document Has Been Signed on 04/29/2024 12:31 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:FULLERTON PLAZA GUEST HOMESFACILITY NUMBER:
306005247
ADMINISTRATOR:MANGURAY, SEANFACILITY TYPE:
740
ADDRESS:3931 MADONNA DRIVETELEPHONE:
(657) 378-9603
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 4DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gerald DiaTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. The Administrator's (Sean Manguray), Administrator's Certificate expires on January 8, 2025, LPA and staff toured the facility. The facility is a one story home with 6 bedrooms, 3 bathrooms, living room with a screened fireplace, kitchen, dining room and a two car attached garage. LPA observed the see something say something poster (PUB 475) posted in the entry way of the facility is 8 1/2 by 11 inches. LPA observed all resident rooms had the required furnishings. LPA observed all resident rooms were clean and organized. LPA observed all 3 bathrooms were clean and operational. LPA observed the ceiling light and ceiling vent fan in bathroom 1 were non-operational. Bathroom 1 had a vanity light mounted above the sink. Hot water measured 105.2 degrees Fahrenheit in all bathrooms. LPA observed a 2 day perishable and a 7 day non-perishable food supply in the kitchen. LPA observed the medications are kept locked in the garage in a tool cart. The garage is kept locked and used for storage. LPA inspected the first-aid kit. LPA observed the first aid kit did not have a current edition first aid manual. The smoke detectors/carbon monoxide detectors tested operational. LPA observed the fire extinguishers in the dining room and kitchen are fully charged. No obstacles or hazards observed inside of the facility. LPA and staff toured the backyard. There is covered patio for residents to sit outside. The exit gate is latched and self closing. No bodies of water observed in the backyard. No obstacles or hazards observed in the backyard. LPA reviewed 4 resident files. No discrepancies observed in any of the resident files. LPA reviewed all 4 resident medications. No discrepancies observed. LPA reviewed 3 staff files. No discrepancies observed. All 3 staff files reviewed had the required training. The last emergency drill was conducted on February 14, 2024. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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 5


Document Has Been Signed on 04/29/2024 12:31 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: FULLERTON PLAZA GUEST HOMES
FACILITY NUMBER: 306005247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5