306005504-1-16-2025-22-AS-BLOZ-DCZ2YF-20250116164841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005504
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:48:52 PM

Document Has Been Signed on 01/16/2025 04:48 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:	OUR LADY OF GUADALUPE HOME		FACILITY NUMBER:	306005504
ADMINISTRATOR/ DIRECTOR:	CRESENCIA D. SANTIAGO		FACILITY TYPE:	735
ADDRESS:	24361 BRIDGER RD		TELEPHONE:	(949) 328-9784
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	01/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Administrator Cresencia Santiago		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiver staff after explaining the purpose for the visit. Administrator (AD) Cresencia Santiago was notified via telephone and later arrived to assist with the inspection. LPA observed Cresencia Santiago has a valid Administrator certificate which expires on September 17, 2025.

The facility is an Adult Resident Facility (ARF) licensed for six ambulatory clients. The facility is a single-story home with four client bedrooms, one staff room, two shared client bathrooms, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage. LPA accompanied by the AD conducted a tour of the physical plant. On today's visit, LPA observed four clients in care and one caregiver staff present. LPA inspected the four client bedrooms, and they were observed to be free of any hazards. LPA observed the client bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All client beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the two shared client bathrooms. Resident bathrooms are clean. Faucets and toilets were operational. Hot water temperature measured between 105.8 and 109.5 degrees Fahrenheit. LPA observed the facility has an emergency food and water supply stored in a hallway closet.

LPA observed the kitchen has a two-day perishable and seven-day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The four burner gas stove lights unassisted. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies are stored in a locked kitchen cabinet under the stove.

A fire extinguisher is located in a the kitchen, and it was observed the be charged and purchased on July 29, 2024. LPA tested the wired smoke detector/carbon monoxide detector which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 7, 2024.The centrally stored medication is kept in a locked storage cabinet in the living room. CONTINUED ON LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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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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: OUR LADY OF GUADALUPE HOME	FACILITY NUMBER: 306005504
	VISIT DATE: 01/16/2025

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LPA observed the First Aid kit has all the required components. The door leading to the laundry room is kept locked and inaccessible to clients in care. The door leading to the attached two car garage is kept locked and inaccessible to clients. The garage is used for storage.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for client use. LPA observed two chemicals to be stored in an unlocked storage cabinet by the client seating area. The perimeter gates on the westside and eastside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all four client files. All the required documentation were present and current in the client files reviewed. The facility handles Personal and Incidental expenses (P&I) for one out of four clients. LPA reviewed four clients’ medication and medication records. LPA reviewed three staff files. LPA observed that the caregiver present at the time of visit was did not have a background clearance and was not associated to the facility. LPA observed caregiver staff exit the premises at time of visit.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Cresencia Santiago. A copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/16/2025 04:48 PM - It Cannot Be Edited

Created By: Brandon Lopez On 01/16/2025 at 04:33 PM

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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 which poses an immediate health and safety risk to persons in care. During a tour of the exterior portion of the facility, LPA observed one bleach container and one multipurpose cleaner container stored in an unlocked storage cabinet by client seating area. AD immediately removed the chemicals and stored it in the locked garage.
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	AD agreed to provide an in service training to staff regarding the storage of chemicals and toxins. AD agreed to provide proof of training to LPA via email or fax by POC date.

Type A

Section Cited

CCR

80019(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. During a review of staff files, LPA observed that the caregiver staff present at the time of visit did not have a background clearance and was not associated to the facility. Per review of LIC500 dated April 20, 2024, caregiver staff started employment at the facility on April 14, 2024. LPA reviewed Guardian at time of visit and there is no background clearance record on file.
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	LPA observed the caregiver staff leave the premises at the time of visit. LPA advised AD that the caregiver staff can not return until they have a background clearance. AD agreed to review regulations regarding criminal backround clearance. AD agreed to submit a plan on how to correct the issue to LPA via email or fax by POC 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:

Sheila Santos

LICENSING EVALUATOR NAME:

Brandon Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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