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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006079
Report Date: 02/12/2024
Date Signed: 02/12/2024 05:25:12 PM


Document Has Been Signed on 02/12/2024 05:25 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:HEALING STEPS GUEST HOMESFACILITY NUMBER:
306006079
ADMINISTRATOR:JOHN CLARENCE ORTIZFACILITY TYPE:
740
ADDRESS:8184 CAROB STTELEPHONE:
(657) 256-1233
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 5DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:John Ortiz, Mae OrtizTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator John Ortiz and explained the reason for the visit. Facility is a 6 bedroom two story house with a living room, dining room, kitchen, 3 bathrooms and an attached 2 car garage. The second story has two bedrooms, family room and a bathroom and is off limits to residents. LPA observed the living room (entrance room for the facility) has the See Something Say Something Poster (PUB 475) posted. LPA and Administrator toured the facility. LPA observed the fireplace in the dining room is screened. LPA observed the resident rooms were clean and organized. Both bathrooms were clean and operational. Hot water measured 120.0 degrees Fahrenheit in both bathrooms. LPA observed all medications are kept locked in a closet. LPA and Administrator toured the kitchen. The kitchen is clean and organized. LPA observed all cleaning supplies and sharp objects are kept locked under the kitchen sink. LPA observed the stove lights unassisted. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Smoke detectors and the carbon monoxide detector tested operational. The garage is kept locked and used for storage. LPA toured the backyard. There is a covered patio with a seating area to sit outside. No bodies of water observed. The shed in the backyard is used for storage and kept locked. Both exit gates are latched and operational. No obstacles or hazards observed inside or outside of the facility. The First Aid kit has all the required elements. LPA reviewed 2 staff files. LPA observed 1 out of 2 staff did not have the required annual training (Staff 1). LPA reviewed 5 out of 5 resident files, no discrepancies observed. LPA reviewed 5 out of 5 resident medications and their medication administration records (MAR), no discrepancies observed. Licensee Mae Ortiz arrived at the end of the visit. LPA consulted with Administrator and Licensee concerning reporting requirements. Deficiencies are being cited per Title 22 division 6 of the California Code of regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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Document Has Been Signed on 02/12/2024 05:25 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: HEALING STEPS GUEST HOMES
FACILITY NUMBER: 306006079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff members which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Licensee agrees to train Staff 1 to meet requirements of the regulation listed above. Licensee to provide proof of correction to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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