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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005570
Report Date: 07/29/2024
Date Signed: 07/29/2024 12:56:24 PM

Document Has Been Signed on 07/29/2024 12:56 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:SAN GIOVANNI BOSCO RESIDENTIAL CAREFACILITY NUMBER:
306005570
ADMINISTRATOR/
DIRECTOR:		JOHN PIRAINOFACILITY TYPE:
740
ADDRESS:24596 DARDANIA AVETELEPHONE:
(949) 583-9143
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Nestor Angeles- CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection using the CARE Tool. LPA was greeted and granted entry by Caregiver Nestor Angeles and Administrator Elizabeth Joaquin was advised of the visit by telephone approximately 9:55am. During today's visit, LPA observed two residents in care and one live-in caregiver on duty.

LPA observed the facility to be clean and sanitary. There are six resident bedrooms and three resident bathrooms. There is an additional private bedroom for the staff. All common areas were inspected including the attached two car garage and laundry room. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 117.5, 117.6, and 119.1 degrees Fahrenheit. LPA observed the indoor temperature was within a comfortable range. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstructions. The exit gate was in good repair. LPA observed sufficient seating and shading. Facility maintains a fire extinguisher which was mounted, charged, and serviced on April 10, 2024. The auditory devices and smoke/carbon monoxide detectors were tested and operational. Emergency disaster supplies including food/water were present. Emergency evacuation drills were not conducted on a quarterly basis with the last drill on June 20, 2021. The first aid kit contains all necessary elements.

LPA observed the required 'See Something, Say Something' (PUB475) poster in an incorrect size posted on the bulletin board in the hallway in the size of 8.5"x11." LPA verified that Administrator Elizabeth Joaquin has completed all course work on May 24, 2024.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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 07/29/2024 12:56 PM - It Cannot Be Edited


Created By: Jessica Cho On 07/29/2024 at 12:23 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: SAN GIOVANNI BOSCO RESIDENTIAL CARE
FACILITY NUMBER: 306005570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, facility did not obtain a medical assessment for R1 which poses a potential risk to the Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Administrator stated that the LIC602 for R1 will be submitted to LPA via email by POC due date.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on interview and record review, facility does not have a TB test result on file for R1 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Adminstrator stated that the TB test result for R1 will be submitted to LPA via email by POC due date.
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:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


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: SAN GIOVANNI BOSCO RESIDENTIAL CARE
FACILITY NUMBER: 306005570
VISIT DATE: 07/29/2024
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LPA conducted an audit of two residents' files and two personnel files. Facility did not obtain a medical assessment and Tuberculosis test for Resident #1 (R1). Residents/staff interviews were conducted and medications were audited. No discrepancies noted.

Based on the observations made during today's visit, deficiencies are being cited. Advisory Notes are being issued.

An exit interview was conducted with Administrator Elizabeth Joaquin by telephone approximately 12:38pm and Caregiver Nestor Angeles signed the report on behalf of the administrator. A copy of this report and the appeal rights were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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