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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006066
Report Date: 02/06/2025
Date Signed: 02/06/2025 03:57:18 PM

Document Has Been Signed on 02/06/2025 03:57 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:CALIFORNIA GUEST HOMEFACILITY NUMBER:
306006066
ADMINISTRATOR/
DIRECTOR:		TODRERA, MICHAELFACILITY TYPE:
740
ADDRESS:2840 E QUINCY AVETELEPHONE:
(562) 388-5088
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 6DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:06 PM
MET WITH:Marjori FacinalTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On February 6th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting an annual visit. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Marjori Facinal and LPA Vanegas explained the nature of the visit. LPA Vanegas set up equipment and began a tour of the facility and observed the following.

This is a two storied home with six bedrooms two of which are staff rooms and four of which are resident rooms. There are three bathrooms two of which are resident bathrooms and one of which is a staff bathroom. There is also an attached two car garage. LPA Vanegas observed the kitchen area to be clean and free of mildew and debris. LPA Vanegas observed there to be an electric stove, microwave, refrigerator, and dishwasher all which tested to be operational and in good repair. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food.

LPA Vanegas observed resident bathrooms to be clean and free of mildew and debris. Water faucet and toilets tested to be operational, and bathrooms contained all required items such as grab bars, slip resistant floor matts, and a shower chair. Water in bathrooms tested to be between 114.3 and 123.2 degrees. LPA Vanegas observed client rooms to have all required furnishings such as a bed, clean linens in good repair meaning no strains or tears, chest drawers, and a reading lamp. However one room did not have a screen on the window a deficiency was cited on today's date.
LPA Vanegas observed outside of facility to be clean and have no obstructions along the emergency exit route. Back yard is clean and in good repair, and big enough to participate in outdoor activities upon resident request. There is an outdoor shaded sitting area, and side doors are unlocked and self latching. LPA Vanegas observed all medications, toxins, and sharps to be locked away and inaccessible to clients in care.
LPA Vanegas observed fire extinguisher to be fully charged and up to date, and for all carbon monoxide detectors and smoke detectors to be operational and in good repair.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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: CALIFORNIA GUEST HOME
FACILITY NUMBER: 306006066
VISIT DATE: 02/06/2025
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LPA Vanegas reviewed three staff files and six resident files all resident files contained all the required documents and all staff training was undocumented. A deficiency was cited on today's date. LPA Vanegas reviewed first aid kit and it contained all required items such as scissors, adhesive tape, tweezers, first aid manual, and a thermometer.

LPA Vanegas reviewed medications and medication administration record (MAR) and per LPA Vanegas review all medications are being administered per physician's orders and they are being documented correctly. Based on today's observations deficiencies will be cited per title 22 chapter six of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/06/2025 03:57 PM - It Cannot Be Edited


Created By: William Vanegas On 02/06/2025 at 03:05 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: CALIFORNIA GUEST HOME
FACILITY NUMBER: 306006066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of four client rooms not having a screen on the window which poses a potential safety risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Administator will order a screen for resident window and send proof of correction via email before P.O.C Due date.
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of three staff members not having documented training availiabe for licnesing review which poses a potential health and safety risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Administrator will conduct and document training, and send proof of correction via email to LPA before P.O.C 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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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