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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006174
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:46:30 PM

Document Has Been Signed on 09/18/2024 04:46 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:SOPHIA'S GUEST HOMEFACILITY NUMBER:
306006174
ADMINISTRATOR/
DIRECTOR:		ESTEBAT, MARLENEFACILITY TYPE:
740
ADDRESS:14891 HOPE ST.TELEPHONE:
(657) 210-4914
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 2DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Marlene Estebat- AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On September 18, 2024, at 2:00pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Administrator (AD) Marlene Estebat.

The facility is licensed to operate for three (3) ambulatory residents and three (3) nonambulatory residents of which one (1) may be bedridden and have a hospice waiver for two (2) residents. The facility is a two story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) Staff Bedroom, four (4) bathrooms, living area, dining area, staff office room, resident kitchen, staff kitchen, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with AD Estebat. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Staff Room 1, and Staff Room 2. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 113.7 degrees F to 115.3 degrees F. A comfortable temperature of 77 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The two kitchens were inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the kitchen.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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: SOPHIA'S GUEST HOME
FACILITY NUMBER: 306006174
VISIT DATE: 09/18/2024
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-760-4101) remains available. First Aid kit had all the necessary elements. The facility has three (3) fire extinguishers that were fully charged, mounted in the kitchen near the entrance, resident hallway, and the staff kitchen that were all serviced on August 20, 2024.

LPA Kim conducted an audit of two (2) resident files (R1-R2), eight (8) staff files (S1-S8), and medication and medication administration review were all in order and complete. LPA Kim conducted two (2) staff interview and two (2) resident interviews.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Marlene Estebat.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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