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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005310
Report Date: 07/06/2021
Date Signed: 07/07/2021 02:57:49 PM

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 2FACILITY NUMBER:
306005310
ADMINISTRATOR:MAGHBOULEH, KATAYOUNFACILITY TYPE:
740
ADDRESS:26545 AVENIDA DESEOTELEPHONE:
(949) 716-1907
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Administrator Katayoun "Kathy" Magbouleh TIME COMPLETED:
11:50 AM
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) Albert Marin conducted an unannounced required annual inspection in this facility. LPA spoke with Administrator Kathy Magbouleh and stated the purpose of this visit.

The facility is single level structure licensed for capacity of six non-ambulatory of which all may be bedridden and with hospice waiver for six. For this visit, there were four residents under hospice care.

About 10:44 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA observed four residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were six private resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were provided with grab bars; non-skid floor mats, and hot water was measured at 111 degrees Fahrenheit. Facility met the two-day perishable and seven-day non-perishable minimum food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion of the facility, patio furniture were observed in to be in good repair, and grounds were free of tripping hazards. Exterior exit doors were self-closing and self-latching.

LPA reviewed and provided assistance with the Guardian system.

LPA reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Magbouleh; and copy of this report was left in the facility.

***Note: This is an amended report. Correct time of visit was from 10:42 AM to 11:50 AM.***
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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 1