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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005352
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:54:33 PM

Document Has Been Signed on 10/30/2024 02:54 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:DIGNITY & WISDOMFACILITY NUMBER:
306005352
ADMINISTRATOR/
DIRECTOR:		TESFAY, SABAFACILITY TYPE:
740
ADDRESS:17331 VINEWOOD AVENUETELEPHONE:
(714) 368-9058
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 4DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Saba Tesfay, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 1 PM. During today’s visit, LPA met with Saba Tesfay, Administrator (AD).

The facility is a single story home with four bedrooms, three bathrooms, a sunroom and a detached garage with an approved fire clearance of six non-ambulatory residents, of which one may be bedridden, and an approved hospice waiver for three. The facility currently has a census of four residents in care and one resident on hospice.

At 2 PM LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperatures in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 105.1 and 105.4 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on August 5, 2024. The facility’s last fire drill was conducted on June 21, 2024 and an earthquake drill was conducted on September 20, 2024.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid Kit had all the required elements and facility has a First Aid binder.

(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DIGNITY & WISDOM
FACILITY NUMBER: 306005352
VISIT DATE: 10/30/2024
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(Continued from LIC 809)

LPA reviewed two of two staff training and fingerprint records and conducted a complete review of resident records. Postural supports were on file for each resident. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. Residents were engaged with the volunteer that comes a few hours per week and enjoyed the children who were visiting. LPA confirmed that administrator has a current administrator certificate which expires on May 30, 2025.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Saba Tesfay, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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