306006065-10-26-2022-22-AS-JHAY-CKKSMZ-20221026140046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006065
Report Date: 10/26/2022
Date Signed: 10/26/2022 02:01:08 PM

Document Has Been Signed on 10/26/2022 02:01 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ST. MARCOS CARE HOME		FACILITY NUMBER:	306006065
ADMINISTRATOR:	PESIGAN, FELIX		FACILITY TYPE:	735
ADDRESS:	6353 SAN MARCOS WAY		TELEPHONE:	(714) 723-0341
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 4		CENSUS: 1	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Maria Ilagan		TIME COMPLETED:	02:10 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staffed called Licensee Melody Bungcayao via telephone as LPA entered the facility. Administrator (AD) Felix Pesigan was has a current administrators certificate that expires 08/05/23.

At 11:05 AM LPA Haley and staff began the inspection at the entrance of the facility. There was one clients present during the visit. A screening station with a thermometer, surgical mask, and hand sanitizer was observed right next to the front door.

Clients bedrooms were clean, organized, and had all necessary requirements: night stand, chair, lamp and storage space. The client bathroom was clean and organized. Hot water temperature was measured at 105.2 degrees Fahrenheit. In the hallway near the the client rooms and bathroom, there's a closet used to store clean linen and bath towels for the clients. On the other side of the living room there is another client bedroom, a staff room and bathroom the client also use. The hot water temperature in bathroom #2 was measured at 118.2 degrees Fahrenheit.

The living room was clean and organized. Between the living room and the staff and client room LPA observed a small office desk and computer set up. Next to the computer LPA observed a locked cabinet used to store facility supplies. In the cabinet LPA observed the following supplies: soap, shampoo, toothpaste, N95 mask, hand sanitizer, bleach wipes, laundry detergent, and trash bags. Next to the cabinet was an emergency survival kit with the following items: emergency food, box water, flash light, face mask, tissue, and toilet bags. Across from the cabinet LPA observed a washer and dryer. Near the washer and dryer LPA observed a locked medication cabinet, and in the locked medication cabinet were a few first aid kits with all the required elements. One of the first aid kits was new and still in the plastic wrapping.

Continued on LIC809C Dated 10/26/22

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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: ST. MARCOS CARE HOME	FACILITY NUMBER: 306006065
	VISIT DATE: 10/26/2022

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The kitchen was clean and organized. Knives and sharp objects locked in a drawer next to the stove. Three of four burners on the stove were operational, and the top left burner would not light. All hazardous chemicals were locked under the kitchen sink. LPA Haley observed a 2 day supply of perishable items and a 7 day supply of non-perishable items neatly organized in the cabinets. A fully charged fire extinguisher was mounted on the wall right outside the kitchen.

The backyard had clear walkways, free of tripping hazards. LPA observed a side exit gate that is self closing and self latching. LPA Haley observed a basketball court and a fitness machine for the clients to enjoy. Two storage sheds were observed. In the first shed LPA observed some old electronic equipment. Staff advised LPA Haley, the electronics are in the process of being removed. Storage shed #2 is used to store adult diapers. LPA observed a rabbit cage in the rear portion of the backyard. There was section on the side of the facility with clutter and debris that need to be removed. The clutter and debris on the side of the house was blocked off by a gate; however, LPA advised staff and licensee Melody Bugcayao the importance of keeping the facility clean and free of clutter and debris at all times. The garage remains locked at all times. There were several tools observed in the garage. LPA observed a couch, dressers, a small refrigerator with some perishable items, some containers of food sitting on the table between the TV and couch, and several pairs of shoes. A TV was mounted on the wall.

No bodies of water were observed. Smoke detectors tested operational.

Deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report, LIC 9102 (Technical Violation), and appeal rights were provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/26/2022 02:01 PM - It Cannot Be Edited

Created By: Jerome Haley On 10/26/2022 at 01:23 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST. MARCOS CARE HOME	FACILITY NUMBER: 306006065
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80076(a)(21)

Food Services (a) In facilities providing meals to clients, the following shall apply: (21) Equipment necessary for the storage, preparation and service of food shall be provided, and shall be well-maintained. This requirement is not met as evidenced by: While inspecting the kitchen area, LPA Haley observed the top left burner on the stove would not light without assistance.
	Deficient Practice Statement
1 2 3 4	Based on observation and acknowledgement from staff, the licensee did not comply with the section cited above which poses a potential health risk to persons in care.
	POC Due Date: 11/04/2022
	Plan of Correction
1 2 3 4	Licensee Melody Bungcayao agrees to have the stove replaced or repaired by the close of business Friday, November 4, 2022.

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:

Luz Adams

LICENSING EVALUATOR NAME:

Jerome Haley

LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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