306005721-2-19-2025-22-AS-BLOZ-DE2W5B-20250219155852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005721
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:59:05 PM

Document Has Been Signed on 02/19/2025 03:59 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:	CYECREST GUEST HOME		FACILITY NUMBER:	306005721
ADMINISTRATOR/ DIRECTOR:	LUU, CHI V		FACILITY TYPE:	740
ADDRESS:	139 S LINCOLN STREET		TELEPHONE:	(714) 785-9555
CITY:	ORANGE	STATE: CA	ZIP CODE:	92866
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Administrator Tin Le		TIME VISIT/ INSPECTION COMPLETED:	04:13 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Tin Le was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Tin Le's certificate expired on November 28, 2024. However, LPA verified and confirmed that Administrator Tin Le submitted an Administrator renewal application to the Administrator Certification Bureau on November 25, 2024. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, and has a hospice waiver for four. The facility is a single story home with five resident bedrooms, one of which is shared, one staff room, three resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed six residents in care and two care giving staff present. LPA observed the resident relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected all five resident bedrooms and they were observed to be free of any hazards. LPA observed the resident bedrooms had all the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway cabinet. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Resident bathrooms were equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 119.1 and 119.3 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to residents in care. LPA observed that the kitchen has a two day perishable and a seven day nonperishable food supply on hand. The kitchen is clean and appliances were operational. LPA observed the five burner gas stove lights unassisted. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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: CYECREST GUEST HOME	FACILITY NUMBER: 306005721
	VISIT DATE: 02/19/2025

NARRATIVE

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LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed toxins and chemicals to be stored in a locked kitchen cabinet under the sink.

A fire extinguisher is located in the dining room and in the resident hallway. Fire extinguishers were observed to be charged and serviced as of May 9, 2024. LPA tested the dual smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 3, 2024. The centrally stored medication is kept in a locked closet in the living room. LPA observed a First Aid Kit to be stored in the locked closet and it was observed to have all the required components. LPA observed a fireplace in the dining room and it was observed to be adequately fenced and not in operation at time of visit. LPA observed chemicals and toxins to be stored in a locked cabinet in the resident hallway. LPA observed the door leading to the attached two car garage is kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA, accompanied by the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion of the facility to be free of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side and south side of the facility are self-latching and can be open in an evacuation. There are no bodies of water on the premises.

LPA reviewed all six resident files. LPA observed that the Reappraisals for Resident #1 (R1), Resident #3 (R3), and Resident #4 (R4) were outdated. LPA reviewed all six residents' medication and medication record. LPA reviewed two staff files. LPA observed that Staff #1 (S1) and Staff #2 (S2) did not have a Health Screening Report on file. All staff are background cleared and associated to the facility.

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

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/19/2025 03:59 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CYECREST GUEST HOME	FACILITY NUMBER: 306005721
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Based on staff file review, LPA observed that there is not a Health Screening Report on file for Staff #1 (S1) and Staff #2 (S2).
	POC Due Date: 03/05/2025
	Plan of Correction
1 2 3 4	AD agreed to get a Health Screening Report for Staff #1 and Staff #2. AD will submit the completed Health Screening Reports for S1 and S2 to LPA via email or fac by POC date.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Based on resident file review, LPA observed that the Reappraisals for Resident #1 (R1), Resident #3 (R3), and Resident #4 (R4).
	POC Due Date: 03/05/2025
	Plan of Correction
1 2 3 4	AD agreed to complete a new Reappraisal for Resident #1 (R1), Resident #3 (R3), and Resident #4 (R4). AD agreed to submit the completed Reappraisals for R1, R3, and R4 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.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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