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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005504
Report Date: 03/22/2022
Date Signed: 03/22/2022 03:57:15 PM

Document Has Been Signed on 03/22/2022 03:57 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:OUR LADY OF GUADALUPE HOMEFACILITY NUMBER:
306005504
ADMINISTRATOR:CRESENCIA D. SANTIAGOFACILITY TYPE:
735
ADDRESS:24361 BRIDGER RDTELEPHONE:
(949) 328-9784
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Cresencia D. SantiagoTIME COMPLETED:
11:30 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 Analysts (LPAs) Lydia Martinez and Jessica Cho made an unannounced visit to the facility to conduct a Required - 1 Year visit. Upon arrival LPA's met with Administrator Cresencia D. Santiago. The focus of today's visit is Infection Control. The facility was toured with AD Santiago and the following was observed:

Facility has no active COVID-19 cases in facility. There are 2 clients present during today's. COVID signs were posted in the facility and a sanitization station was set up near the front entrance. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Restrooms observed contained soap, and toilet paper. Paper towels are provided when needed due to clients flushing down the toilet. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. LPA's observed a full bathroom in the garage with staff's personal belonging and portable folding camping cot. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Clients were observed in their room. Administrator Certificate for Cresencia Santiago expires on 09/17/2023. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication cabinet for Client medication and files are kept in locked hallway closet. During walk through of the facility, LPA's observed 1 bottle of Robitussin cough syrup; 1 bottle of pain relief tablets and 1 prescription bottle for Karelto 15mg on top of cabinet in TV room and a bottle of Gummy Vitamins in Client 1 room.
During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. LPA advised the importance of mask wearing and hand washing for staff, visitors and client. Administrator was reminded to review Department PINS in regards to Masking, Staff and Resident Testing, Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment.

Based on observations made during today’s inspection, the following deficiency is cited as per Title 22 of the California Code of Regulations. An exit interview was conducted, copy of report to be emailed to AD Santiago.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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 3
Document Has Been Signed on 03/22/2022 03:57 PM - It Cannot Be Edited


Created By: Lydia Martinez On 03/22/2022 at 10:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: OUR LADY OF GUADALUPE HOME
FACILITY NUMBER: 306005504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that LPA's observed 4 bottles of medication made accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2022
Plan of Correction
1
2
3
4
Staff locked away medication during the visit. AD to conduct in-service staff training on section cited and submit proof to LPA Martinez on or before 3/29/2022
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:Marina Stanic
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3