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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005247
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:04:15 PM

Document Has Been Signed on 08/29/2024 01:04 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:FULLERTON PLAZA GUEST HOMESFACILITY NUMBER:
306005247
ADMINISTRATOR/
DIRECTOR:		MANGURAY, SEANFACILITY TYPE:
740
ADDRESS:3931 MADONNA DRIVETELEPHONE:
(657) 378-9603
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:31 PM
MET WITH:Gerald DiaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On August 29, 2024, Licensing Program Analysts (LPA) Edward Kim and Jerome Haley conducted a Case Management visit in regards to observations made while investigating Complaint# 22-AS-20240826143729.

During record review,while reviewing the Physician's Report and Appraisals and Needs Services Plan were incomplete. Signatures were missing on Appraisals and Needs Services Plan and signature and date were missing on the Physician's Report.

A deficiency was cited during the inspection visit according the California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and the appeal rights were provided to Administrator Gerald Dia. .
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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Document Has Been Signed on 08/29/2024 01:04 PM - It Cannot Be Edited


Created By: Edward Kim On 08/29/2024 at 12:42 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: FULLERTON PLAZA GUEST HOMES
FACILITY NUMBER: 306005247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87506(a)

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87506 (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Licensee states they will read and review section 87506 Resident Records and send a signed statement acknowledging they have read and understood the regulation to CCLD via email to edward.kim@dss.ca.gov by POC due date September 6, 2024.
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Based on observation and record review, Licensee did not comply with the section cited above. LPA observed for R1 Appaisal and Needs Service plan was missing a signature and the Physician's report was missing a signature and date. This poses a potential health, safety, and personal rights risks to persons in care.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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