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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606024
Report Date: 09/09/2025
Date Signed: 09/09/2025 02:06:36 PM

Document Has Been Signed on 09/09/2025 02:06 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:MAUREEN GUEST HOMEFACILITY NUMBER:
300606024
ADMINISTRATOR/
DIRECTOR:		MCKENZIE, VICTORFACILITY TYPE:
740
ADDRESS:9362 MAUREENTELEPHONE:
(714) 539-0391
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 5DATE:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Victor MckenzieTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Licensee (LE), Victor McKenzie and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are five residents, of which three are on hospice during today's visit.

LPA Tea reviewed five resident files and two staff files. Resident files had the required documentation. There were discrepancies in staff files. LPA observed outdated First Aid/CPR training. There is current staff training for one staff last conducted in November 2024. Licensee misplaced the current training for the other staff. There is currently no qualified administrator. The designated administrator nor licensee does not have a valid administrator certificate.

LPA Tea along with the licensee toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms were missing and some did not operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. At first the bathrooms did not have good up keeping but caregivers cleaned up the restrooms afterwards. LPA reminded licensee to maintain the cleanliness of the bathroom and facility. There should be no cobwebs, spiders and other insects at all. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 119.3 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was

(Annual report continued on LIC809C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/09/2025 02:06 PM - It Cannot Be Edited


Created By: Michael Tea On 09/09/2025 at 12:25 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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, resident rooms did not have smoke detectors and some of them are no longer working. This poses as a potential health and safety risk to residents in care.
POC Due Date: 10/07/2025
Plan of Correction
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Licensee replace the smoke detectors with operational ones and get new ones for rooms missing smoke detectors by POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During the physical plant tour LPA discovered the screen door for the sliding back door is broken, taken off. This poses as potential health and safety risk to residents in care.
POC Due Date: 10/07/2025
Plan of Correction
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Facility will fix the sliding the door by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2025 02:06 PM - It Cannot Be Edited


Created By: Michael Tea On 09/09/2025 at 12:25 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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of records, there is currently no qualified administrator for the facility. Recent administrator passed away. Designated administrator does not have administrator certificate. Licensee does not have a qualified administrator certificate. This poses as a potential health and safety risk to residents in care.
POC Due Date: 10/07/2025
Plan of Correction
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Facility/Licensee will show proof that designated Administrator will be obtaining their administrator certificate 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2025 02:06 PM - It Cannot Be Edited


Created By: Michael Tea On 09/09/2025 at 12:39 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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the medication was stored in boxes in the living room and not in a locked secured centrally stored location. This poses as an immediate health and safety risk to residents in care.
POC Due Date: 09/10/2025
Plan of Correction
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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2025 02:06 PM - It Cannot Be Edited


Created By: Michael Tea On 09/09/2025 at 12:53 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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements ... Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of staff records, staff have outdated First Aid and CPR training. This poses as a potential health and safety risk to residents in care.
POC Due Date: 10/07/2025
Plan of Correction
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Facility will have caregivers obtain first aid/CPR certification by POC due date
Type B
Section Cited
CCR
87465(h)(6)
Incidental Medical and Dental Care ... The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of medication, facility does not properly maintain a centrally stored medication list. Some residents had some, some just had a list. This poses as potential health and safety risk to residents in care.
POC Due Date: 10/07/2025
Plan of Correction
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Facility will created a centrally stored medication list for each resident that lists routine and PRN medication for every month. Creating a new medication list for each month, and keep the old ones for record keeping by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2025 02:06 PM - It Cannot Be Edited


Created By: Michael Tea On 09/09/2025 at 01:10 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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Emergency Plans(a)(2) ... Facility must plan to be self-reliant for a period of at least 72 hours immediately following any emergency or disaster (including a long-term power failure).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of emergency supplies, facility had expired emergency food and not enough water for residents for at least 72 hours during an emergency and disaster.
POC Due Date: 10/07/2025
Plan of Correction
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Facility will get new emergency food supply that is not expired and more cases of water for emergency 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Michael Tea
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


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: MAUREEN GUEST HOME
FACILITY NUMBER: 300606024
VISIT DATE: 09/09/2025
NARRATIVE
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inspected. Perishable and non-perishable food supply was checked and adequately stocked at the time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to residents in care under the kitchen sink and in cabinets by the laundry area. The fire extinguisher in the kitchen is fully charged. The kitchen appliances are operational. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility are self-latching and operational. LPA observed not enough emergency supplies for 72-hour reliance. The emergency food was expired. There was not enough water for residents during an emergency disaster. Facility provides activities based on resident interests and health conditions. They play small ball games and do body exercises, especially chair exercises. At the time of annual visit, residents were seen having lunch, watching television in the living room and family visitors came to visit.

LPA reviewed medication storage and administration. Medications are not stored in a secured centrally stored location. Medications are being administered per physician order. Medications are not tracked properly or have proper consistent record keeping like with a centrally stored medication list. LPA interviewed residents regarding their quality of care and spoke to staff present regarding the care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Licensee Victor McKenzie and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102TV and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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