306005840-8-15-2022-22-AS-ETAA-CHBP8M-20220815110546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005840
Report Date: 08/15/2022
Date Signed: 08/15/2022 11:05:58 AM

Document Has Been Signed on 08/15/2022 11:05 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	NOTHING HILLS GUEST HOME LLC		FACILITY NUMBER:	306005840
ADMINISTRATOR:	MIRABUENO, MARIA		FACILITY TYPE:	740
ADDRESS:	13901 HEWES AVENUE		TELEPHONE:	(657) 267-0067
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	6	CENSUS: 5	DATE:	08/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Basilio Aquino, Maria Isabel Ewell		TIME COMPLETED:	11:15 AM

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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Basilio Aquino and Maria Isabel Ewell and stated the purpose of this visit. Administrator Maria Mirabueno was unable to make the visit. The facility is a single level structure and licensed for six ambulatory of which six can be non-ambulatory with a hospice waiver for six. This facility is a Residential Care Facility for the Elderly/Dementia. At about 9:25 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 5 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms 2 of which were able to be shared rooms. The facility also had a staff room which is inaccessible to residents. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. LPA noticed in room 3 paint needed to be retouched and staff was made aware of this issue. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 134.9 degrees Fahrenheit. LPA noticed that a light bulb needed to be replaced. Staff member stated it would be too bright for the residents and took off unused light bulbs. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 127.7 degrees Fahrenheit. LPA informed staff of the regulation for water temperature. Staff will adjust water temperature. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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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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: NOTHING HILLS GUEST HOME LLC	FACILITY NUMBER: 306005840
	VISIT DATE: 08/15/2022

NARRATIVE

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Garage is kept locked and is accessed from the staff room. Facility offers a 2-car garage which is used for storage with an operational washer and dryer and a truck. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, one deficiency was noted in areas observed. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with staff Basilio Aquino and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/15/2022 11:05 AM - 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: NOTHING HILLS GUEST HOME LLC	FACILITY NUMBER: 306005840
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

878303(e)(2)

This requirement is not met as evidenced by: Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of two restrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2022
	Plan of Correction
1 2 3 4	Administrator will adjust water tempature to meet regulation requirements.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3