306005567-7-22-2022-22-AS-JHAY-CGKUMQ-20220722154243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005567
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:42:52 PM

Document Has Been Signed on 07/22/2022 03:42 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:	QUEZON HOME CARE VILLA		FACILITY NUMBER:	306005567
ADMINISTRATOR:	QUEZON, SIMON P		FACILITY TYPE:	740
ADDRESS:	12631 LORALEEN ST		TELEPHONE:	(714) 583-8182
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 3	DATE:	07/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Simon Quezon		TIME COMPLETED:	03:48 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff, and explained the reason for the visit. Facility staff called Administrator (AD) Simon Quezon who arrived at the end of the inspection. AD Quezon has a current administrators certificate that expires 10/24/22.

There is a screening station set up right next to the front door, and all required postings on the wall through out the facility. There were three residents present during todays visit.

At 1:40 PM LPA Haley began the tour with staff inspecting resident rooms and bathrooms. All resident bedrooms were clean, organized, and had all necessary requirements. All bathrooms were clean and organized. Hot water temperatures measured at 105.5 degrees Fahrenheit in bathroom #1 and 106.1 degrees Fahrenheit in bathroom #2. In the hallway closet near resident room #1 LPA observed plenty of extra linen and a mounted and charged fire extinguisher on the wall in the closet.

In the garage LPA Haley observed clear walkways free or tripping hazards, a washer and dryer, and extra linens stored in the cabinets above the washer and dryer. There is an employee area/office set up in the garage with a desk and chair. Staff files were observed on the shelf on the desk in the garage. LPA observed an emergency supply of food and water, and emergency bins with emergency supplies for all the residents .

The back yard was clean and free of clutter and debris. A shaded area with tables and chairs was observed. The side exit gate was self closing and self latching. There was a storage shed in the backyard with various items used by the staff.

LPA observed a locked medication cabinet mounted on the wall and locked medication refrigerator in the dining room. There was a first aid kit in the file cabinet next to the medication cabinet with all the required elements. Resident files are also stored in the file cabinet in the dining room .

Continued on LIC 809C Dated 7/22/22

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUEZON HOME CARE VILLA	FACILITY NUMBER: 306005567
	VISIT DATE: 07/22/2022

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In the kitchen LPA Haley observed a 2 day supply of perishable food items and a seven day supply of non perishable food items. Knives are locked in a drawer. There is an additional first aid kit mounted on the wall near the refrigerator. Around 2:18 PM LPA observed serval gnats gathered on top of some fruit in the corner of the kitchen near the sink. Around 2:25 PM while checking the stove LPA Haley and Administrator Quezon observed four of the five burners working on the stove. The burner in the front left corner would not light without assistance.

No bodies of water were observed during today's visit. All smoke detectors were tested and are operational.

Deficiencies are being cited during todays visit. An exit interview was conducted and a copy of the report and appeal rights were provided to Administrator Simon Quezon.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/22/2022 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUEZON HOME CARE VILLA	FACILITY NUMBER: 306005567
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation 87303 (a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenace shall include provision of maintenance services and procedures for the safety and well being of residents, employees, and visitors. This requirement is not met as evidenced by: the front left corner burner on the stove would not light without assistance.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with Administrator Quezon, the licensee did not comply with the section cited above which poses a potential safety risk to persons in care.
	POC Due Date: 07/29/2022
	Plan of Correction
1 2 3 4	Administrator Quezon will call a repair man to come see if the stove needs to be cleaned, repaired, or replaced.

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: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

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