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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003594
Report Date:
10/17/2024
Date Signed:
10/17/2024 01:23:38 PM
Document Has Been Signed on
10/17/2024 01:23 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:
LOIS GUEST HOME II
FACILITY NUMBER:
306003594
ADMINISTRATOR/
DIRECTOR:
MARICEL WRIGHT
FACILITY TYPE:
740
ADDRESS:
17562 MEDFORD AVENUE
TELEPHONE:
(714) 573-7697
CITY:
TUSTIN
STATE:
CA
ZIP CODE:
92780
CAPACITY:
6
CENSUS:
5
DATE:
10/17/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:
Lilosa Manalili
TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and William Vanegas conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 10/01/2024. LPA's were greeted and granted entry into the facility and explained the reason for the visit.
At 12:10PM LPA's toured the facility and observed the following:
Deficiency cited under Title 22 Regulation 87555(b)(8) pertaining to food quality has been cleared. LPA's observed food to be in good quality. Licensee has complied with the POC.
Deficiency cited under Title 22 Regulation 87465 (h)(2) pertaining to centrally stored medications has been cleared. LPA's observed medications are centrally stored and inaccessible to residents in care. Licensee has complied with the POC.
Deficiency cited under Title 22 Regulation 87303(e)(2) pertaining to water temperature has NOT been cleared. LPA's tested water temperature to be between 122-126.8 F degrees. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED.
Deficiency cited under Title 22 Regulation 87303(a) pertaining to maintenance and operation has NOT been cleared. LPA's observed the wall in the jack and jill restroom is still in need of repair. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Armando J Lucero
LICENSING EVALUATOR NAME
:
William Vanegas
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/17/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2024
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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