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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005627
Report Date: 09/27/2024
Date Signed: 09/27/2024 10:32:41 AM

Document Has Been Signed on 09/27/2024 10:32 AM - 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:SAINT JUDE GUEST HOMEFACILITY NUMBER:
306005627
ADMINISTRATOR/
DIRECTOR:		PINILI, MARISONFACILITY TYPE:
740
ADDRESS:612 S PINE DRIVETELEPHONE:
(714) 519-3632
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 4DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Marison PiniliTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA was allowed entry into the home and met with Direct Support Professionals (DSP's) Eva Laureta and DaisyAnn Samparani. Administrators (AD) Marison Pinili arrived shortly after. AD Pinili has an Administrator Certificate which expires on 11/28/2024. Facility is a Residential Care Facility for the Elderly (RCFE) vendored by Orange County Regional Center (RCOC). There was one of four Clients present during today's visit. Three clients are at Day Program. LPA, along with DSP Laureta toured the physical plant. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked and toilets and water faucets worked properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. Appliances are operational. LPA observed sharps and cleaning supplies locked in a kitchen cabinet and in the garage. Smoke detectors and carbon monoxide detector tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked and self-latching. Backyard has a covered patio, patio furniture for outdoor activities and sufficient seating for clients and visitors. Last Emergency/Fire Drill was conducted on 09/03/2024 and are conducted monthly. LPA observed emergency supplies including food and water in dining room closet. LPA reviewed four client files and two staff files. Client files contained required documentation such as health assessments and admission agreements. Staff files contained required documentation including fingerprint clearance and required training. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately. P & I money matched facility ledger. Liability and Surety Insurance certificate is current. Based on observations made during today’s visit, no deficiencies are being cited. This report was discussed with Administrator and a copy was sent to email on file.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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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