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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006175
Report Date: 03/12/2024
Date Signed: 03/13/2024 07:11:12 AM


Document Has Been Signed on 03/13/2024 07:11 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:HOLY FAMILY GUEST HOMEFACILITY NUMBER:
306006175
ADMINISTRATOR:DAMICOG, TERESITAFACILITY TYPE:
740
ADDRESS:13372 GARDEN GROVE BLVDTELEPHONE:
(714) 643-0661
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:6CENSUS: 3DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Mylene Baldazo and Teresita DamicogTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Holy Family Guest Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 2 non-ambulatory residents and 4 ambulatory residents. Facility has an approved hospice waiver for 2 residents and there are no residents on hospice during today's visit. There are 3 residents present. Teresita Damicog has an Administrator Certificate expiring on 06/26/2024. Administrator Teresita Damicog was present during the inspection.

LPA Lyman along with Administrator Teresita Damicog toured the facility at 9:44 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of four resident bedrooms, one staff room, one shared hall bathroom, one staff bathroom, living room and kitchen. Facility has all required postings including personal rights and complaint poster. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured at 106.1 degrees F in facility bathroom. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards, doorways were free of obstructions. Facility is clean and sanitary. First aid kit had all the required elements including tweezers, thermometer, and scissors. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents as well as unlocked and self latching exit gates. LPA observed emergency food and water supply in the garage. LPA reviewed the emergency disaster plan and infection control plan during the visit. CONTINUED ON LIC 809C DATED 03/12/2024.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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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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: HOLY FAMILY GUEST HOME
FACILITY NUMBER: 306006175
VISIT DATE: 03/12/2024
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Plans are thorough and complete. Facility provided documentation of last fire drill conducted on 01/10/2024. Facility provides activities in the form of games and exercise. At 10:15 AM, LPA reviewed three resident files and five staff files. Resident files contained required documents including admission agreements and current physician reports. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 10:45 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are inaccessible to residents in care. Facility uses a medication administration record and medications are being administered per physician order.

Based on the observations made during today's visit, no deficiencies are being cited.
Exit interview conducted and a copy of this report was given at time of visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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