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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005508
Report Date: 02/15/2022
Date Signed: 02/16/2022 04:22:41 PM

Document Has Been Signed on 02/16/2022 04:22 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: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: 5DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH: Administrator Brevit Dao and Enriqueto Miang AoTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley and Licensing Program Manager (LPM) Sheila Santos conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA and LPM were greeted, granted entry by staff Enriqueto and explained the reason for the visit. Staff contacted via phone call Administrator Brevit and arrived at the facility at 10:25am. LPA observed there's a screening log book, thermometer for screening clients and visitors. At 9:15am LPA and LPM toured the facility with staff Enriqueto. There were five residents in care at the facility. LPA began the tour checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and dresser. Bathrooms were operational and clean. In Bathroom #1 LPA and LPM observed an unlock cabinet under the sink with five total hazardous cleaning materials. The water temperature in resident's common bathroom measured initially measured 127F then another attempt was made and measured 117F degrees. The resident personal bathroom measured 110F degrees.The facility have enough two day supply of perishable and seven days supply of nonperishable food. There was a first aid kit equipped with all required items. The stove was clean and all five burners were operational. LPA observed knives in a locked cabinet under the sink next to cleaning solutions.The facility has adequate PPE supply of gloves, N95 mask, surgical mask, and hand sanitizers. LPA observed extra linen, emergency food and water supply. LPA toured the backyard and observed both side exit gates of the house were self closing and self latching. The right side exit gate was observed to be lock and inaccessible. Administrator removed the lock and now accessible. LPA observed a pile of loose garden tools and a pair of large gardening scissors out in the open accessible to ambulatory resident. Administrator secured the loose garden tools and a pair of large gardening scissors during the visit. There were no bodies of water observed. Wired smoke detectors were tested and are operational. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. A copy of the LIC809d and LIC9102 were explained and provided to Administrator during the visit. An exit interview conducted and a copy of the appeal rights were given to the Administrator at time of visit. A copy of the report was provided to the Administrator.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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 02/16/2022 04:22 PM - It Cannot Be Edited


Created By: Jerome Haley On 02/15/2022 at 12:32 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: LOMITA GUEST HOME
FACILITY NUMBER: 306005508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)(2)


This requirement is not met as evidenced by: During the visit the following were observed: unsecured gardening tools in the backyard, medication accessible to the residents on the dining table and unsecured cleaning supplies under the resident's bathroom sink. The facility has one dementia resident. (Pictures were taken by LPA during the visit).
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section citted below:
87705-Care of Pesons With Dementia
(f)The following shall be stored inaccessible to residents with dementia:
(1)Knives,matches,firearms,tools and other items that could constitute a danger to the resident(s).
(2)Over the counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants,gardening supplies,cleaning supplies and disinfectants which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2022
Plan of Correction
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During the visit LPA/LPM observed the administrator/staff secured the garden tools in the locked garage, medications were secured in the locked medication cabinet, cleaning supplies were removed and locked in a cabinet. The Administrator will conduct training to all staff about the above regulation. A copy of the proof of training will be provided to the LPA by due date 02/22/22.
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022


LIC809 (FAS) - (06/04)
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