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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000089
Report Date: 01/21/2025
Date Signed: 01/21/2025 05:09:26 PM

Document Has Been Signed on 01/21/2025 05:09 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:VALLEY GUEST HOMEFACILITY NUMBER:
306000089
ADMINISTRATOR/
DIRECTOR:		DULCE S.ARGOSINOFACILITY TYPE:
740
ADDRESS:10413 OWL CIRCLETELEPHONE:
(714) 963-7423
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Emma Firme, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On January 21, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA Bentley met with Administrator (AD) Emma Firme and explained the reason for the visit. Certification for the administrator was verified with an expiration date of September 25, 2026.

The facility is a one story structure located in a residential neighborhood and consists of the following: three (3) private resident bedrooms, one (1) shared resident bedroom, two (2) caregiver bedrooms, 3 bathrooms for residents and staff, living-room, family room, kitchen, dining area, back yard, and garage. Facility is licensed to operate for six (6) non-ambulatory residents and maintains a hospice waiver for four (4). There were six (6) residents in care during today's visit of which four (4) are in hospice.

LPA Bentley toured the interior and exterior of the facility with AD Firme and observed the facility to be clean and sanitary. All common areas were inspected including all resident rooms. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be operational with the water temperatures measured between 111.3 degrees and 119.5 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two day supply of perishables and seven day supply of non-perishable food. The fireplace was covered with a screen and secure. Facility maintains two fire extinguishers, one on each side of the building. Both were charged and serviced on July 3, 2024. The smoke detectors and carbon monoxide detectors were operable. The backyard was clean with sufficient seating and covered shading. The exit gates were both operational and self-closing. No bodies of water were observed.

CONTINUED NEXT LIC 809-C PAGE...

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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: VALLEY GUEST HOME
FACILITY NUMBER: 306000089
VISIT DATE: 01/21/2025
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During the visit, LPA Bentley observed the facility's infection control practices, Dementia plan of operation, and a fire and disaster plan. The last fire drill was conducted on December 7, 2024. A working telephone (714-963-7423) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency water, and additional supplies were stored in the garage. Liability Insurance is effective July 1, 2024 and expires on July 1, 2025. First aid kit is properly maintained and contains all the necessary elements.

LPA Bentley conducted an audit of six (6) resident files (R1-R6), three (3) staff files (S1-S3), medication and medication administration review. Two (2) staff interviews and five (5) resident interviews were conducted.


Based on the observations made during today's visit, no deficiency is being cited, per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted with Administrator Emma Firme, and a copy of this report was provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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