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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005800
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:20:39 PM

Document Has Been Signed on 03/16/2023 03:20 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:FOUNTAIN GARDEN GUEST HOMEFACILITY NUMBER:
306005800
ADMINISTRATOR:LUU, CHI VFACILITY TYPE:
740
ADDRESS:16803 MAPLE ST.TELEPHONE:
(714) 602-1515
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chi "Rex" LuuTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year Annual inspection. Upon arrival LPA was greeted and granted entry by Carestaff Hermelinda Palma and May Ong. LPA began inspection with introduction and visit purpose. There are currently 6 Residents residing and present at the facility. Facility currently has 1 resident receiving Hospice care. Administrator (AD) Chi "Rex" Luu arrived shortly after.

LPA along with AD Rex conducted a tour of the inside and outside of the facility. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the Residents. Lighting is sufficient for safety and comfort. The facility is a two story, 5 bedroom, 3 bathroom home with a dining room, living room, kitchen, and attached garage on first floor. The second floor has 2 bedrooms, and 1 bath that is used by staff only. There is a back yard with a patio cover for the residents. Resident bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. Water temperature tested at 115.7 degrees F. Linen and hygiene supplies were stocked in 2 hallway closets. Emergency Phone Numbers and Exit Plan were reviewed. Food prep areas are clean and organized. Food supply does not meet the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Emergency food and water supply is available. Smoke detectors are centrally wired and carbon monoxide detectors were found to be operational. LPA and AD observed the 3 Fire Extinguishers that were mounted were last serviced on 04/15/2021. Stove burners, microwave, washer, and dryer are operational. There is a locked location for chemicals and sharps in the kitchen. Laundry is done in the garage, and there is a locked cabinet for storing laundry soap and other chemicals. Medications are centrally stored in a locked metal file cabinet. Medications reviewed appear to have been dispensed accurately.

(see LIC809C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FOUNTAIN GARDEN GUEST HOME
FACILITY NUMBER: 306005800
VISIT DATE: 03/16/2023
NARRATIVE
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First-Aid Kit and Activity Supplies, were observed and available. There is a working land line at the facility. The LIC610, Emergency Disaster Plan is posted. Facility’s licensing fees are fully paid.

Indoor passageways are free of obstruction. LPA noted an old box spring and an old commode on the side of home by the exit gate. LPA also observed the exit gate is not self latching and scrapes at the bottom.

Resident Files/Incident Reports/Personal Rights/Incidental Medical and Dental - LPA reviewed 3 Resident files. LPA noted Admission Agreement, Medical Assessment and TB test results, Identification and Emergency information, Appraisal Needs and Service Plan, Consent forms, Centrally Stored Medication/Destruction Records, Safeguard for Personal Property/Valuables, and Personal Rights Notification.

Personnel Records/Training/and Staffing- Two (2) records were reviewed. LPA reviewed employee records for First Aid certification, Finger Print Clearance, Personnel/Job Application, Health Screening and TB test results, Criminal Record Statement, Employee Rights, and Training Verification. Administrator is unable to provide proof of initial and/or Annual training for Staff 1 and Staff 2. Administrator Certification, expires on 07/25/2023.

LPA interviewed 2 of the 6 residents and 1 staff. LPA reviewed medication for 2 Residents.

Based on the information received during this visit today in the areas reviewed, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/16/2023 03:20 PM - It Cannot Be Edited


Created By: Lydia Martinez On 03/16/2023 at 11:43 AM
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: FOUNTAIN GARDEN GUEST HOME
FACILITY NUMBER: 306005800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 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:
Deficient Practice Statement
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Based on observation, the Administrator did not ensure the facility’s Fire Extinguisher was serviced annually, (last serviced on 04/15/2021),which poses an immediate health and safety risk to the persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Administrator will have the Fire Extinguishers serviced or purchase new Fire Extinguishers and submit proof to LPA by POC due date of 03/17/2023.
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This regulation was not met as evidenced by:
Deficient Practice Statement
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Based on observations, the facility failed to have sufficient food supplies for all residents in care for the two (2) days perishable and (7) seven days non-perishables required. This poses an immediate health and safety risk to the persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Administrator to ensure that at minimum two (2) days perishable and seven (7) days non perishables food supply for residents in care is maintained. Administrator to provide proof of two (2) days perishable and seven (7) days non perishables is supplied by 03/17/2023.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/16/2023 03:20 PM - It Cannot Be Edited


Created By: Lydia Martinez On 03/16/2023 at 11:56 AM
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: FOUNTAIN GARDEN GUEST HOME
FACILITY NUMBER: 306005800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Based on the individual's preadmission appraisal... Postural supports may be used under the following conditions: Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care...This req is not being met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed a full bed rail on bed of R1. Staff reported R1 is not on Hospice services. This poses an immediate risk to residents safety.
POC Due Date: 03/17/2023
Plan of Correction
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Administrator to remove the full bed rail and/or obtain a physician orders for a half-bed rail if there is a need and submit proof to LPA by 03/17/2023.
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance . All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the Administrator did not transfer S2's criminal record clearance. This poses an immediate risk to the health and safety of the residents in care.
CIVIL PENALTY ASSESSED
POC Due Date: 03/17/2023
Plan of Correction
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Administrator to ensure all staff have proper criminal record clearance transfer pursuant to regulation and submit written proof to LPA by POC due date of 03/17/2023.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/16/2023 03:20 PM - It Cannot Be Edited


Created By: Lydia Martinez On 03/16/2023 at 01:01 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: FOUNTAIN GARDEN GUEST HOME
FACILITY NUMBER: 306005800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
The California Code of Regulations Section 87411(c)(6) Personnel Requirements - General indicates that "The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2)"

This requirement is not met as evidenced by:
Deficient Practice Statement
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Administrator is unable to provide proof of initial and/or Annual training for staff. Based on records reviewed, the Administrator did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator to schedule make up sessions of the missing initial and/or annual training sessions and provide documentation of completion before the Plan of Corrections due date of 03/31/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5