306005309-6-18-2024-22-AS-JCHO-D6D2TC-20240618174031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005309
Report Date: 06/18/2024
Date Signed: 06/18/2024 05:42:22 PM

Document Has Been Signed on 06/18/2024 05:42 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:	QUEEN'S HOME I		FACILITY NUMBER:	306005309
ADMINISTRATOR:	MAGHBOULEH, KATAYOUN		FACILITY TYPE:	740
ADDRESS:	24422 ZANDRA DRIVE		TELEPHONE:	(949) 716-1835
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	06/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Arya Maghbouleh- Administrator		TIME COMPLETED:	06:00 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) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Inspection using the Care Inspection Tool. LPA Cho was greeted and granted entry by Administrator (Admin) Arya Maghbouleh and explained the reason for the visit. The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory of which all may be bedridden and maintains a hospice waiver for six (6). There are three (3) residents under hospice and one (1) bedridden resident during today's visit. LPA toured the interior and exterior portions of the facility. There are a total of five resident bedrooms and two resident bathrooms. There are two staff bedrooms. LPA observed the facility to be clean and sanitary. The resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke/carbon monoxide detectors and auditory exit alarms were tested and operational. LPA observed bathrooms to be in good repair, provided with handrails, and a non-skid floor mat. The hot water temperature measured at 117.3 and 115.5 degrees Fahrenheit in the resident bathrooms. Facility met the two day perishable and seven day non-perishable food supplies. LPA observed medications, toxins, and sharps were inaccessible to the residents. The three fire extinguishers were purchased on today's date. LPA observed clutter in the garage which is a safety hazard. For the exterior portion, facility had sufficient seating and shading. The exit doors were self-closing and self-latching. LPA observed the emergency disaster supplies including food/water. LPA observed the required "See Something, Say Something' (PUB475) poster in the required size. Administrator's Certificate for Kathy Maghbouleh expires on 12/06/24. LPA conducted an audit of six residents' files and two staff files. No discrepancies noted however please ensure that the health screening for the staff is completed by June 22, 2024. Staff and resident interviews were conducted. Medications were audited. No discrepancies noted.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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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Document Has Been Signed on 06/18/2024 05:42 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: QUEEN'S HOME I	FACILITY NUMBER: 306005309
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, facility did not maintain documentation of the doctor's orders for the full bed rails for R4 and R6 which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	Administrator stated that proof of doctor's orders for the full rails for R4 and R6 will be submitted to LPA via email by POC due date.

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 Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUEEN'S HOME I	FACILITY NUMBER: 306005309
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, facility did not obtain TB testing and its results for R1, R3, R4, and R6 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator stated that proof of TB test results for R1, R3, R4, and R6 will be submitted to LPA via email by POC due date.

Type B

Section Cited

CCR

87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA observed clutter and was unable to walk through the garage which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Adminstrator stated that they will clean the clutter in the garage and to submit a photograph to LPA via email by POC due date.

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 Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUEEN'S HOME I	FACILITY NUMBER: 306005309
	VISIT DATE: 06/18/2024

NARRATIVE

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LPA consulted the following: to clear the clutter in the garage in order to adhere to the regulations by the State Fire Marshal, to obtain a medical assessment and Tuberculosis test results using the Physician's Reports (LIC602s), to ensure a medical assessment including the health screening is completed for an employee, to obtain doctor's orders for the full bed rails, and to conduct and maintain a log for the earthquake drills.

Based on the observations made during today's visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See the attached LIC90999Ds. A Technical Violation is being issued today. See the attached LIC9102.

An exit interview was conducted with Administrator Arya Maghbouleh, and a copy of this report including the LIC809C, LIC809Ds, LIC9102, LIC811s, and the appeal rights were provided during this visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 06/18/2024 05:42 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: QUEEN'S HOME I	FACILITY NUMBER: 306005309
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, facility did not obtain and provide documenation of a recent medical assessment for R6 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator stated that proof of LIC602 will be submitted to LPA via email by POC due date.

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 Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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