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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003515
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:53:11 PM

Document Has Been Signed on 03/11/2022 02:53 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:MARY'S ASSISTED HOME LIVINGFACILITY NUMBER:
306003515
ADMINISTRATOR:MAUREEN SALONGAFACILITY TYPE:
740
ADDRESS:11642 DALE STREETTELEPHONE:
(714) 537-0899
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 5DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Maureen SalngaTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit today. Administrator (AD) Maureen R. Salonga arrived at the end of the visit. AD Salonga has a current administrators certificate that expires on 10/24/2022. LPA observed all required postings on the walls throughout the facility. LPA was screened, temperature checked and oxygen levels were taken before entering the facility. LPA observed a screening station at the entrance of the facility. Staff member Audie led the tour of the facility. There were five residents in care at the facility, two were observed on the couch enjoying TV, and two others were observed in their rooms. LPA began the tour checking client rooms and bathrooms. Client rooms were clean, organized and free of clutter. All resident rooms have the necessary elements. Bathrooms were operational and clean. At 1:19 PM in residents room bathroom #1 LPA measured the water temperature at 130 degrees F. At 1:24 PM in Bathroom #2 water temperature was measured at 132.9 degrees F. At 1:30 PM in resident room bathroom #3 LPA measured the water temperature at 131.7 degrees F. The kitchen was clean and well organized. The stove was clean and all four burners were operational. All knives and sharp objects were locked in a drawer, and all cleaning chemicals were locked under the sink. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. There was a first aid kit equipped with all required items in a locked hallway medication closet. There was a second locked medication closet on the opposite side of the hallway with more resident medication. In the caregiver break room the facility has and adequate supply of emergency PPE. There's also a locked cabinet with discontinued medications. LPA toured the backyard and observed both side exit gates of the house were self closing and self latching. LPA observed a shaded patio area in the backyard with tables and chairs for the residents in care. There were no bodies of water observed. Wired smoke detectors were tested and are operational. LPA consulted AD Salonga, and staff Audie on the importance of keeping an adequate supple of emergency food and water.
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator Salonga and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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Document Has Been Signed on 03/11/2022 02:53 PM - It Cannot Be Edited


Created By: Jerome Haley On 03/11/2022 at 02:16 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: MARY'S ASSISTED HOME LIVING

FACILITY NUMBER: 306003515

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)(e)(2)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(e)Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
Deficient Practice Statement
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Based on observation of the bathroom temperatures mesuring between 130 - 132.9 degrees F in all three bathrooms the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2022
Plan of Correction
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Administrator Salonga states water temperature will be adjusted to meet the regulation requirements cited above.
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
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