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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000089
Report Date: 02/14/2022
Date Signed: 02/14/2022 03:20:02 PM

Document Has Been Signed on 02/14/2022 03:20 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VALLEY GUEST HOMEFACILITY NUMBER:
306000089
ADMINISTRATOR:DULCE S.ARGOSINOFACILITY TYPE:
740
ADDRESS:10413 OWL CIRCLETELEPHONE:
(714) 963-7423
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Emma Firme - AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Valley Guest Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Administrator (AD) Emma Firme. Caregiver Diego Firme was also present. The facility is licensed for 6 non-ambulatory residents. The facility also has a hospice waiver for 4 residents. There are currently 4 residents living in the facility. The last emergency disaster drill was conducted on January 30, 2022.

At 2:08 PM LPA Velazquez conducted a tour of the physical plant along with AD Firme. The 1 story home consists of 5 resident bedrooms and 2 staff bedrooms with 3 bathrooms. The 4 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature ranged from 117.6 to 121.2 degrees Fahrenheit. LPA Velazquez inspected the kitchen with AD Firme. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Toxins, sharps, and medications were locked and inaccessible to residents. First aid kit was checked and found to be in order. The First Aid manual was noted to be outdated which AD Firme verified.

LPA Velazquez along with AD Firme toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gates were operational. The auditory alarms were noted to be in operating condition. There were no security bars or weapons on the premises.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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: VALLEY GUEST HOME
FACILITY NUMBER: 306000089
VISIT DATE: 02/14/2022
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No client or staff files were reviewed at the time of this visit. LPA Velazquez observed bed rail orders for residents with bed rails but advised AD Firme to obtain updated bed rail orders to indicate the need for the bed rails. AD Firme indicated she would obtain updated bed rail orders and place in the resident files.



There were no deficiencies issued during this Required 1 Year visit. An exit interview was conducted with Administrator Emma Firme and a copy of this report along with a copy of a 9102 TA were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC809 (FAS) - (06/04)
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