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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000924
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:25:38 PM

Document Has Been Signed on 02/19/2025 01:25 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:QUEEN MARY GUEST HOMEFACILITY NUMBER:
306000924
ADMINISTRATOR/
DIRECTOR:		EVANGELINE BRUNOFACILITY TYPE:
740
ADDRESS:442 N. SYRACUSE ST.TELEPHONE:
(714) 952-2269
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:19 AM
MET WITH:EVANGELINE BRUNOTIME VISIT/
INSPECTION COMPLETED:
03:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA met with Administrator (AD) Evangeline Bruno and discussed the purpose of the inspection.
LPA toured the interior and exterior facility and observed the following:
The facility is a one-story and has 4 bedrooms, living room with screened fireplace, family room with a screened fireplace, eat in kitchen 2 bathrooms and a detached two car garage that is used for storage.LPA and AD tested smoke detectors/carbon monoxide in common areas and bedrooms; all were operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably.

LPAs observed fire extinguisher mounted in kitchen and garage areas with last inspection date of on March 8th, 2024. Upon review of record, emergency drill log indicated that the last drill was conducted in January of 2025.


LPA observed sharps sand knives locked in the kitchen and are inaccessible to residents in care. However, LPA observed the medication cabinet opened and unlocked. The medication cabinet was in the kitchen.
Restrooms toilets and water faucets were also observed to be operational. Grab bars were secure, and showers were observed to be free of mold/mildew. Water temperature measured between at 117.6 degrees Fahrenheit and 118.9 degrees Fahrenheit. LPAs and AD toured the backyard of the facility and observed a shaded seating area for residents’ enjoyment. LPA checked emergency exits to be free of obstacles. LPA reviewed two residents’ and two staff files and observed they all had the required documentation.

Based on the observations made during today’s inspection, ONE deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights provided to AD at end of inspection.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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Document Has Been Signed on 02/19/2025 01:25 PM - It Cannot Be Edited


Created By: Samer Haddadin On 02/19/2025 at 01:01 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: QUEEN MARY GUEST HOME
FACILITY NUMBER: 306000924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

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 observation, the licensee did not comply with the section cited above in leaving the medication cabinet open and accessible to residents which poses an immediate health, safety risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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AD locked cabinet . No POC
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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