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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003399
Report Date: 04/12/2022
Date Signed: 04/12/2022 12:09:32 PM

Document Has Been Signed on 04/12/2022 12:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:QUEEN MARY GUEST HOME IIFACILITY NUMBER:
306003399
ADMINISTRATOR:EVANGELINE BRUNOFACILITY TYPE:
740
ADDRESS:8089 TEAKWOOD CIRCLETELEPHONE:
(714) 484-8880
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald Daaca, Evangeline Bruno TIME COMPLETED:
12:20 PM
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Licensing Program Analysts (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with lead staff Ronald Daaca and stated the purpose of this visit. AD Evangeline Bruno arrived during the visit at 9:10 AM and provided assistance.

The facility is a single level structure and licensed for six non-ambulatory of which 3 non-ambulatory and 2 ambulatory. This facility is a Residential Care Facility for the Elderly.

About 9:00 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 clients in care and two staff members on the duty. LPA toured the interior and exterior portions of the facility. There were 2 shared client's rooms, One client private room and one staff room. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. LPA noticed in Bedroom (1) tools and medication were visible and staff immediately removed and locked. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 121.4 degrees Fahrenheit. Bathroom( 2) was observed to be in good repair and provided with grab bars and hot water was measured at 122.0 degrees Fahrenheit. Bathroom (2) had cleaning wipes which staff removed immediately and locked. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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: QUEEN MARY GUEST HOME II
FACILITY NUMBER: 306003399
VISIT DATE: 04/12/2022
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Fire extinguisher was on observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Ladders were observed on the side of the garage and moved where they were inaccessible to clients. Garage is kept locked and used for storage. Laundry room was in good repair. Kitchen was in good repair with medications kept locked. LPA noticed scissors and had staff removed and put them in a locked area. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with AD Evangeline Bruno and copy of this report was explained and left in the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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