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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006240
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:40:58 PM

Document Has Been Signed on 03/19/2025 03:40 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:HOUSE OF HOPE OF BUENA PARKFACILITY NUMBER:
306006240
ADMINISTRATOR/
DIRECTOR:		CINTRON, VIVIANA REYNAGAFACILITY TYPE:
740
ADDRESS:8441 SAN MARINO DRTELEPHONE:
(562) 325-0572
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Administrator- Viviana CintronTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On March 19, 2025, at 12:20 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Silvia Heredia Silva. Administrator (AD) Viviana Cintron arrived around at 12:35 PM and LPA Kim explained the purpose of the visit.

The facility is licensed to operate for six (6) nonambulatory residents, of which one (1) may be bedridden, and has a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) bathrooms, living area, kitchen, outdoor covered patio, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with AD Cintron. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 115.8 degrees F to 117.1 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility.

LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage.
Evaluation Report Continues on LIC 809-C.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HOUSE OF HOPE OF BUENA PARK
FACILITY NUMBER: 306006240
VISIT DATE: 03/19/2025
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-723-0050) and video teleconferencing device dedicated to the residents both remain available. Last emergency drill was conducted on February 19, 2025 and conducted quarterly. First aid kit is maintained and contains all the necessary elements.

LPA Kim conducted an audit of resident file (R1-R4), staff files (S1-S6), and medication and medication administration record. LPA Kim conducted one (1) Staff interview.

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). LPA observed S1-S5 did not complete the annual 20 hour training for 2024 and 2025.
A technical violation was cited during this visit.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Viviana Cintron
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2025 03:40 PM - It Cannot Be Edited


Created By: Edward Kim On 03/19/2025 at 03:18 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: HOUSE OF HOPE OF BUENA PARK
FACILITY NUMBER: 306006240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

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 observation, interview, and record review, the licensee did not comply with the section cited above in five out of six persons. LPA observed S1-S5 did not have annual 20 hours of training for 2024 and 2025.This poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee states they will submit proof of a schedule/plan and hours completed for 2025 of S1-S5 to CCLD via email to edward.kim@dss.ca.gov by POC due date April 2, 2025.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
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