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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005991
Report Date: 09/28/2022
Date Signed: 09/28/2022 10:44:33 AM


Document Has Been Signed on 09/28/2022 10:44 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:GARDEN GROVE GUEST HOME LLCFACILITY NUMBER:
306005991
ADMINISTRATOR:TISTOJ, RUTHFACILITY TYPE:
740
ADDRESS:12882 SHACKELFORD LANETELEPHONE:
(714) 638-9470
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:47CENSUS: 30DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Ruth TistojTIME COMPLETED:
10:55 AM
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On 09/28/2022 at 9:11am, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Garden Grove Guest Home LLC. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 9:20am, LPA Cho was greeted by Caregiver Hoa Chinch who then led LPA to Receptionist/Medical Technician (MT) Sandra Monzon. MT Monzon notified Administrator (Admin) Ruth Tistoj of LPA's arrival. At 9:30am, LPA met with Admin and verified facility information. At 9:42am, LPA initiated a self-guided tour in the common areas after completing the Coronavirus 2019 (COVID-19) screening procedure and was later joined by Admin around 9:46am. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs on the entrance door and throughout the facility. The Complaint Poster (PUB475) met the size requirement. The facility is licensed for forty-seven non-ambulatory residents and has a hospice waiver for twenty. There are thirty residents living in the facility and none are receiving hospice care as of today.

Around 9:46am, LPA Cho conducted a tour of the physical plant along with Admin Tistoj . The single story facility consists of the following areas which were inspected: TV/Game Room, Medicine Room, Board/Care Dining Room, Beauty Salon, Staff Break Room, Janitor's Closet, Laundry Room, and Kitchen (also shared by the Garden Grove Post Acute Skilled Nursing Facility (SNF) next door. There are a total of 24 bedrooms, 15 bathrooms, and 2 spa showers. LPA Cho along with Admin Tistoj randomly selected and inspected five resident bedrooms and bathrooms. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly and grab bars were secure. The two spa showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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: GARDEN GROVE GUEST HOME LLC
FACILITY NUMBER: 306005991
VISIT DATE: 09/28/2022
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LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 114.8 degrees Fahrenheit in the Bathrooms #1 & #2, 115.5 degrees Fahrenheit in Bathrooms #3 & #4, and 113.3 degrees Fahrenheit in Bathroom #5.

LPA Cho inspected the kitchen along with Admin Tistoj. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged and the auditory devices were operational. The smoke/carbon monoxide detectors were tested by The Regency Fire Protection Maintenance Inc. on 09/13/2022 and were also operational. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds with Admin Tistoj. LPA observed two courtyards adjacent to the resident bedrooms. There was shading and sufficient seating for residents, and the walkways around the facility were clear of hazards. The exit gate was self-closing and self-latching.



LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components, and the facility had sufficient PPEs. LPA reviewed Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides a tablet and iPad upon request.

LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Ruth Tistoj, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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