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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005721
Report Date: 10/05/2021
Date Signed: 10/05/2021 03:40:36 PM

Document Has Been Signed on 10/05/2021 03:40 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:CYECREST GUEST HOMEFACILITY NUMBER:
306005721
ADMINISTRATOR:LUU, CHI VFACILITY TYPE:
740
ADDRESS:139 S LINCOLN STREETTELEPHONE:
(714) 785-9555
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY: 6CENSUS: 3DATE:
10/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee Tin LeTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of Complaint #22-AS-20210604144038. Upon arrival, LPA met with Staff Harry and Amalia Serra. Licensee Tin Le arrived a short while later. During the complaint investigation, it was disclosed that Resident #1 was bedridden. The Licensee is not approved to have bedridden residents as there is no approved bedridden fire clearance.

At the time of visit, LPA also observed the back door exits of the facility to be tied shut with a chair in front of one of the doors. The outside of the doors were also tied shut and a recliner was pushed up against the door from the outside.. When asked why the exits were tied shut and blocked with furniture, LPA was told that Resident #2 tries to "get out" of the facility.

See LIC809D for cited deficiency and civil penalties.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/05/2021 03:40 PM - It Cannot Be Edited


Created By: Michelle Reed On 10/04/2021 at 02:29 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: CYECREST GUEST HOME
FACILITY NUMBER: 306005721

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2021
Section Cited
CCR
87202(a(2)

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Fire Clearance-Prior to accepting or retaining nonambulatory and/or bedridden resident's, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by city or county fire department.

This requirement was not met as evidencesd by:
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Licensee/Administrator understands that bedridden residents may not be admitted or retained in the facility without an approved bedridden fire clearance. Proof of understanding of this subsection will be provided.

Civil penalties assessed.
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Resident #1 was bedridden and the Licensee did not have an approved bedridden fire clearance. This is an immediate Health and Safety risk to residents in care.
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Type A
10/05/2021
Section Cited
CCR87203

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Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement was not met as evidenced by:
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Staff immediately untied doors and moved the furniture. Licensee agreed to provide staff training on keeping exits clear and not violating the rights of residents. Proof of staff training will be provided.

Civil penalties assessed.
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During visit, LPA observed the back door exits to be tied shut and a chair and recliner pushed up against the doors. This is a Health and Safety and Personal Rights risk to residents 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:Sheila Santos
LICENSING EVALUATOR NAME:Michelle Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2021


LIC809 (FAS) - (06/04)
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