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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006126
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:19:36 PM

Document Has Been Signed on 07/17/2024 03:19 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
Lookup Error,
, CA
FACILITY NAME:RDB GUEST HOMEFACILITY NUMBER:
306006126
ADMINISTRATOR/
DIRECTOR:		BANGGALAT, REGIE DANCELFACILITY TYPE:
740
ADDRESS:2351 W. BROADWAYTELEPHONE:
(714) 519-5268
CITY:ANANHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Briones BonifacioTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with House Manager Briones Bonifacio and was granted entry to the facility. The facility is a (4) bedroom (2) bathroom home and, with a kitchen/dining area, living room, and attached garage. Licensed capacity is (6) current census is (4). LPA was accompanied by House Manager Briones Bonifacio to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated space for client/staff files.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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 07/17/2024 03:19 PM - It Cannot Be Edited


Created By: Mary Rico On 07/17/2024 at 03:00 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
,
, CA

FACILITY NAME: RDB GUEST HOME
FACILITY NUMBER: 306006126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 4 resident's did not have their hospice care plan at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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House Manager has agreed to read regulation entirely and send LPA a self-certified letter that the regulation 87633(b) was read and understood. The staff will send proof they have recicved the hospice care plan.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 4 record review did not have an updated medical assesment. R1 last medical assesment was conduct in 2022 as which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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House Manager has agreed to read regulation entirely and send LPA a self-certified letter that the regulation 87705(c)(5)(A) was read and understood. The staff will also send proof they have schedule a medical appointment for R1.
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


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
Lookup Error,
, CA
FACILITY NAME: RDB GUEST HOME
FACILITY NUMBER: 306006126
VISIT DATE: 07/17/2024
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Record Review: LPA reviewed (4) client files for admission agreements, updated physician reports, medications and needs and services plans. 1 out of the 4 clients did not have an updated medical assessment. R1 has dementia and last medical assessment was conducted in 2022. Furthermore, facility did not have R1 Hospice Care Plan maintained at he facility.

LPA conducted (3) medication audit. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, two (2) Type B deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809)(LIC809D) was discussed and provided to House Manager Briones Bonifacio. Along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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