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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006142
Report Date: 08/21/2024
Date Signed: 08/21/2024 10:25:09 AM

Document Has Been Signed on 08/21/2024 10:25 AM - 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:MONROY HOME CARE ASSISTANCEFACILITY NUMBER:
306006142
ADMINISTRATOR/
DIRECTOR:		DURAN, WENDY K.FACILITY TYPE:
740
ADDRESS:24322 FORDVIEW STREETTELEPHONE:
(714) 353-6133
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 1DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Wendy Duran, administratorTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and William Vanegas made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPAs were greeted and granted entry by facility administrator Wendy Duran after introducing himself and stating the reason of the visit.

During the inspection, LPAs and facility staff conducted a tour of the physical plant and observed the following: The facility is a one story home with one private and two shared bedrooms and one staff room in addition to the facility's common living areas. There are two bathrooms (one shared and one en-suite), observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPAs observed all beds have linens and blankets. There are no postural supports in use in the facility at the time of the visit.

There is currently one resident admitted to the facility, not currently receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire and emergency drills have been conducted regularly as confirmed by staff interview but not formally documented since August 2023. LPAs provided consultation on the information needed to be maintained on file.
LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are observed to be fully charged with up-to-date maintenance tags.

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the house and routes of egress are free of obstructions.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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 3
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: MONROY HOME CARE ASSISTANCE
FACILITY NUMBER: 306006142
VISIT DATE: 08/21/2024
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CONTINUED FROM FORM LIC809
    Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPAs reviewed one resident files and three staff files. Resident records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location. One staff member has a physician visit report on file but no health screening confirming that the staff member in question is physically and mentally capable of performing assigned tasks and in good physical health is present on file.

    Based on the observations made during today’s inspection, no deficiencies are being issued per Title 22 Division 6 of the California Code of Regulations. A Technical Violation advisory note is provided with a consultation on the health screening requirements for facility staff An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
    SUPERVISORS NAME: Sheila Santos
    LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 08/21/2024
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 08/21/2024
    LIC809 (FAS) - (06/04)
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