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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005504
Report Date: 01/05/2024
Date Signed: 01/05/2024 12:09:59 PM

Document Has Been Signed on 01/05/2024 12:09 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 ASC, 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:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Administrator - Cresencia Santiago TIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry by Administrator Cresencia Santiago.
The facility is a one-story home with four resident bedrooms, two bathrooms, kitchen, dining room, living room, staff room, laundry room, front patio, back yard and attached two-car garage. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Upon first measuring hot water, it measured below 105 degrees Fahrenheit. The Administrator raised the temperature on the water heater. Hot water took an hour to warm up. Hot water measured at 105.4 degrees Fahrenheit and 105.8 degrees Fahrenheit in both bathrooms. LPA advised AD to keep a more frequent water log since water temperatures were so close to the threshold. LPA observed exit gates in the backyard to be operational and unobstructed. Facility has shaded seating areas on the front patio and in the backyard. Smoke and Carbon Monoxide detectors tested operational. LPA observed facility has emergency food and water supply. Appliances are operational. Facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food. Fire Extinguisher was observed to be fully charged as indicated by the built-in meter. LPA observed client medication to be locked in a cabinet in the living room. Staff files were noted to be locked in a closet near the dining area. LPA reviewed medication for all clients and files for two of the four clients. LPA also reviewed P&I. One client's P&I was short by $100. Administrator corrected this during the inspection. A deficiency is being issued on this day. While reviewing files, LPA also noted that the facility has conducted emergency drills in 2023, but the drills did not occur at least quarterly. LPA reviewed all staff files. All clients were away at day program.
Based on today’s inspection, two deficiencies were issued. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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 01/05/2024 12:09 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 01/05/2024 at 11:50 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: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to the fact that the facility did not hold all of their quarterly drills in 2023. This poses a potential safety risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Administrator stated they will send to LPA via email the missing drill log. If AD cannot find missing drill log, AD stated facility will hold a drill and document it in the drill log by the assigned POC due date of 1/12/2024. AD stated they will email LPA the completed drill documentation by the assigned POC due date.
Type B
Section Cited
CCR
80026(h)(1)
(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on P&I review, the licensee did not comply with the section cited above in one client's P&I. This poses a potential personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Administrator stated they would correct the error during the LPA's inspection. Administrator stated facility will do a weekly review of P&I and will make updates as they arise. Administrator stated they would keep P&I locked up and only one other staff member will have a key to it. LPA will review P&I again during POC visit which will occur after 1/12/2024.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
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