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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005309
Report Date: 05/02/2022
Date Signed: 05/02/2022 01:40:48 PM


Document Has Been Signed on 05/02/2022 01:40 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:QUEEN'S HOME IFACILITY NUMBER:
306005309
ADMINISTRATOR:MAGHBOULEH, KATAYOUNFACILITY TYPE:
740
ADDRESS:24422 ZANDRA DRIVETELEPHONE:
(949) 716-1835
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Kathy MaghboulehTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced required annual (mitigation) inspection in this facility. LPA was greeted and granted entry by Administrator (AD), Kathy Maghbouleh and completed the Coronavirus 2019 screening procedure. LPA stated the purpose of the visit and toured the facility.

The facility is a single level structure and licensed for six non-ambulatory residents of which all may be bedridden and has a hospice waiver for four residents. There are three residents in hospice as of today. For this visit, there are five residents in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 117.3 degrees Fahrenheit in Bathroom #1 and 116.4 degrees Fahrenheit in Bathroom #2. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. The fire extinguishers were mounted and charged. For the exterior portion, facility had outdoor furniture under ample shading. The grounds were free of tripping hazards. Side exit doors were self-latching and self-closing. LPA reviewed the approved COVID-19 Mitigation Plan.

For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and AD will follow-up with the corrections. An exit interview was conducted with Administrator Kathy Maghbouleh and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
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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