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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005508
Report Date: 10/22/2020
Date Signed: 10/23/2020 11:40:53 AM

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:LOMITA GUEST HOMEFACILITY NUMBER:
306005508
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:1919 E LOMITA AVETELEPHONE:
(714) 602-6414
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 3DATE:
10/22/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Brevet Dao TIME COMPLETED:
11:00 AM
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As precautionary measures during the Coronavirus 2019 pandemic, Licensing Program Analyst (LPA) Albert Marin made an unannounced video teleconference visit to conduct a case management for deficiency observed during complaint investigation visit. LPA met with Administrator Brevet Dao and state the purpose of this visit.

LPA Marin conducted a virtual tour of the facility. LPA observed 3 residents in care and two staff members on duty. LPA also observed the telephone unit in the facility. LPA discussed with AD Dao the findings and deficiency found in complaint No. 22-AS-20200619142228; California code of Regulation Sections: 87311, and 87208; and latest Provider information Notice 20-31-ASC. AD Dao discussed the corrective action that they have taken to ensure that the facility landline is at working conditions at all times. Corrective action includes to disconnect the landline from the fax machine and only reconnect when needed; to review phone features and set up a business voicemail feature and train staff to retrieve messages; and provide responsible parties and stakeholders with alternative contact numbers.

Advisory notes - Technical Violation was issued.

LPA Marin conducted an exit interview and read the report with AD Dao. LPA will provide copies of this report and technical violation via email. AD agreed to acknowledge their receipt via email.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
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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