306005991-9-19-2024-22-AS-MTEA-D99VEQ-20240919162244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005991
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:22:50 PM

Document Has Been Signed on 09/19/2024 04:22 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:	GARDEN GROVE GUEST HOME LLC		FACILITY NUMBER:	306005991
ADMINISTRATOR:	TISTOJ, RUTH		FACILITY TYPE:	740
ADDRESS:	12882 SHACKELFORD LANE		TELEPHONE:	(714) 430-3534
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	47	CENSUS: 42	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:01 AM
MET WITH:	Connor Kelley		TIME COMPLETED:	04:37 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) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 47 non-ambulatory residents, with a hospice waiver for twenty-seven. Currently there are 42 residents, zero on hospice during today's visit. The Administrator (AD), Connor Kelley arrived shortly after to assist during the visit.

At 9:15 AM, LPA Tea reviewed eight resident files and four staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly emergency disaster drill, which was last conducted on August 6, 2024.

LPA Tea along with AD Kelley toured the physical plant at 12:13 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story unit building that consists of two hallways with 24 resident rooms and shared Jack and Jill bathrooms. There are common areas, dining/activity room, resident shower rooms, and kitchen for meal preparation and food service. In the front of the facility is the courtyard where there is a shaded patio seating area for residents to enjoy. The kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Emergency food and water supplies were stored separately in storage closets in the hallway. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire and smoke detectors are serviced and maintained through a third-party company. Fire extinguishers are fully charged throughout the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly. Grab bars were secure, and showers were free of mold/mildew.

Annual continuation on LIC809C.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: GARDEN GROVE GUEST HOME LLC	FACILITY NUMBER: 306005991
	VISIT DATE: 09/19/2024

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
26
27
28
29
30
31
32

Water temperature measured between 113.3 F degrees and 115.7 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA Tea observed residents doing dancing and exercises in the activity room. Residents were also watching a movie in the afternoon. Activities are posted in the front desk area in English and Vietnamese with different activities for residents to participate.

At 2:27 AM LPA reviewed medication storage and administration. Medications are stored in carts that are locked and secured. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Connor Kelley and copy of this report LIC809, 809-C, LIC858, LIC858-C and LIC859 was read and provided to the facility.

.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2