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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005310
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:06:50 PM


Document Has Been Signed on 06/18/2024 01:06 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 2FACILITY NUMBER:
306005310
ADMINISTRATOR:MAGHBOULEH, KATAYOUNFACILITY TYPE:
740
ADDRESS:26545 AVENIDA DESEOTELEPHONE:
(949) 716-1907
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Arya Maghbouleh- Administrator
Arlene Mahinay- Administrator		TIME COMPLETED:
01:25 PM
NARRATIVE
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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) Arlene Mahinay and Caregiver Mario Mahinay. Admin Arya Maghbouleh arrived at the facility to assist with the inspection.

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 is one (1) resident under hospice care during today's visit.

LPA toured the interior and exterior portions of the facility. There are a total of six resident bedrooms and six resident bathrooms. There is also one staff bedroom and a private staff bathroom. 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. A camera observed in the bedroom of Resident # 5 (R5) was removed during the visit. 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 116.6, 115.3, 118.2, 120.0, 120.0, and 118.9 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 four fire extinguishers were purchased on today's date. 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 located in the garage. LPA observed the required "See Something, Say Something' (PUB475) poster in the required size. Administrators' Certificates for Kathy Maghbouleh expires on 12/06/24. Administrator Arlene Mahinay whose certificate expired on 08/15/23 provided proof of completed course work during the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 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 01:06 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 2
FACILITY NUMBER: 306005310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
87608 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of six residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Administrator stated that proof of doctor's orders for the full rail for R4 will be submitted to LPA via email by POC due date.
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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 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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Document Has Been Signed on 06/18/2024 01:06 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 2
FACILITY NUMBER: 306005310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
87458 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 diseases or other medical conditions...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of six residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Adminstrator stated that they will provide proof of TB test result for R3 to LPA via email by POC due date.
Type B
Section Cited
CCR
87412(a)
87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out of the two staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Administrator stated that they will gather and complete all missing records for S1 and S2 and provide proof to LPA 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 MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 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)
Page: 3 of 5


Document Has Been Signed on 06/18/2024 01:06 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 2
FACILITY NUMBER: 306005310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one out of the six resident bedrooms by placing a camera in the bedroom of R5 which poses a personal rights risk to persons in care. Camera was removed during the visit.
POC Due Date: 06/28/2024
Plan of Correction
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Administrator stated that they will either submit an exception or no longer utilize the camera moving forward and to submit an Acknowledegment of Understanding for the said deficiency to LPA via email by POC due date
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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 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)
Page: 4 of 5


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 2
FACILITY NUMBER: 306005310
VISIT DATE: 06/18/2024
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LPA conducted an audit of six residents' files and two staff files. Discrepancies noted in the staff file as the records were not available for review. Staff and resident interviews were conducted. Medications were audited for six residents. No discrepancies noted.

LPA consulted the following: to ensure R5 is afforded privacy in their personal bedroom, to obtain a doctor's order for the full rail for one resident, to obtain a Tuberculosis Test (TB) result for one resident, and to ensure personnel records are maintained for each employee.

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.

An exit interview was conducted with Administrators Arya Maghbouleh and Arlene Mahinay, and a copy of this report including the LIC809C, LIC809Ds, LIC811s, and the appeal rights were provided during this visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 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: 5 of 5