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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006081
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:52:54 PM

Document Has Been Signed on 01/23/2025 04:52 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:GOOD MORNINGS HOME CAREFACILITY NUMBER:
306006081
ADMINISTRATOR/
DIRECTOR:		SHOGA, CYNTHIAFACILITY TYPE:
740
ADDRESS:25735 CERVANTES LANETELEPHONE:
(949) 492-3532
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:58 PM
MET WITH:Evelyn Macedo, Head caregiver
Cynthia Shoga, Administrator		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Cynthia Shoga was notified of the visit via telephone and arrived later to assist with the visit.

There are currently five residents in care, two of which are receiving hospice care. LPA observed residents relaxing in their respective bedrooms and in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house. There are five privately occupied bedrooms, in addition to a room for use by overnight staff. There are four bathrooms throughout the facility.

Bedrooms appeared clean and sanitary. Two bedrooms are equipped with full-length rails, however residents are confirmed to not be receiving hospice care at this time. Type B citation issued. LPA observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and slip mats. Hot water temperature measured within the required range in two separate bathrooms with faucets used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Mounted fire extinguishers is charged. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a secure cabinet located in the dining area. Additional storage areas are inaccessible to residents. Cleaning supplies are stored securely in a secure storage locker accessible outside the house as well as under the kitchen sink.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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: GOOD MORNINGS HOME CARE
FACILITY NUMBER: 306006081
VISIT DATE: 01/23/2025
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CONTINUED FROM FORM LIC809
LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating areas with furniture for resident use. The perimeter gate on the side of the property is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed five resident records which included all necessary components. Two residents interviewed during the visit. LPA reviewed resident medication records and prescription orders with no discrepancies observed. There are no bedridden residents present on the premises. LPA reviewed three staff records. At the time of the visit, none of the two staff members present holds a current CPR training as both the administrator and the head caregiver had stepped away from the facility. Type B citation issued. All staff are background cleared and associated to the licensed location accurately.

Based on the observations made during today’s visit, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 04:52 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 01/23/2025 at 04:31 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: GOOD MORNINGS HOME CARE
FACILITY NUMBER: 306006081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as no staff members with valid and current CPR training were present at the start of the present visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee will ensure all staff members have valid CPR training. Proof of training to be provided to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as two residents confirmed to not be admitted under hospice were observed to be in beds equipped with full-length rails for postural support. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee will replace the full-length rails with half rails and ensure updated physician orders are on file.
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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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