Fullerton Plaza Guest Homes

Type of visit: Required - 1 Year

On March 19, 2026, at 8:45AM, 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 Caregiver (CG) Roona Kumaat. LPA Kim met with Assistant Administrator (AA) Gerald Dia and explained the purpose of the visit. The facility is licensed to operate for six (6) nonambulatory residents of which one may be bedridden and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with AA Dia. There were no bodies of water or obstructions in the facility. 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, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 108.3 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility. LPA Kim observed the facility to be 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. Evaluation Report Continues on LIC 809-C The kitchen was inspected and there is a two-day supply of perishable in the kitchen and seven-day supply of non-perishable food in the garage, both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged, mounted next to the dining area exit door, and was last purchased on January 13, 2026. 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 (657-578-9603) and a computer with videoconferencing technology both remain available. The facility has an evidence of liability insurance effective March 20, 2025, and expires on March 20, 2026. They also provided evidence of liability of insurance effective March 20, 2026, and expires on March 20, 2027. Last fire drill was conducted on January 8, 2026, and are conducted quarterly LPA Kim conducted an audit of resident files (R1-R6), staff files (S1-S5), and medication and medication administration record that were all in order and complete. LPA Kim conducted interviews with three (3) residents. No deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Gerald Dia.the state’s words, verbatim · CDSS document, Mar 19, 2026

Type of visit: Required - 1 Year

On January 7, 2025, at 9:10am, 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 House Manager (HM) Ana Santos. LPA Kim met with Assistant Administrator (AA) Gerald Dia and explained the purpose of the visit. The facility is licensed to operate for six (6) nonambulatory residents of which one may be bedridden and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with HM Santos. There were no bodies of water or obstructions in the facility. 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, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 108.3 degrees F to 109.9 degrees F. A comfortable temperature of 69 degrees F was maintained in the facility. LPA Kim observed the facility to be 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 kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food in garage, both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and mounted next to the dining area exit door. Evaluation Report Continues on LIC 809-C 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 (657-578-9603) remains available. The facility has an evidence of liability insurance effective March 30, 2024, and expires on March 20, 2025. Last fire drill was conducted on December 30, 2024. LPA Kim conducted an audit of resident files (R1-R5), staff files (S1-S3), and medication and medication administration record. LPA Kim conducted two (2) staff interviews and two (2) resident interviews. Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. Technical violations were issued at the time of the visit. An exit interview was conducted, and a copy of this report and appeal rights were provided to Assistant Administrator Gerald Dia.the state’s words, verbatim · CDSS document, Jan 7, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not accept resident back after hospital stay.

Licensing Program Analysts (LPAs) Edward Kim and Jerome Haley made unannounced visit to investigation a complaint received August 26, 2024. LPAs Kim and Haley were greeted by staff and explained the reason for the visit before entering the facility. The complaint investigation consisted of interviews with facility staff, residents, witnesses, and document review. Regarding the allegation: Staff did not accept resident back after hospital stay. 3 of 5 individuals interviewed stated the resident decided to move out of the facility. Staff 1 (S1) stated that the resident left on their own. Staff 2 (S2) said, “(the resident) moved out. They took all their clothes and left.” Staff 3 (S3) stated the resident moved out. Continued on LIC9099C Unsubstantiated Witness interviewed stated the resident is cognizant and is able to make their own choices. Document reviewed revealed that resident is “Mentally he is coherent. He makes his own decisions and has no POA,” and “(Resident) is independent and can do things on his own.” Based on the information gathered during the investigation through interviews, record reviews, and observation the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Administrator Gerald Dia.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 22-AS-20240826143729

Type of visit: Case Management - Deficiencies

On August 29, 2024, Licensing Program Analysts (LPA) Edward Kim and Jerome Haley conducted a Case Management visit in regards to observations made while investigating Complaint# 22-AS-20240826143729. During record review,while reviewing the Physician's Report and Appraisals and Needs Services Plan were incomplete. Signatures were missing on Appraisals and Needs Services Plan and signature and date were missing on the Physician's Report. A deficiency was cited during the inspection visit according the California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and the appeal rights were provided to Administrator Gerald Dia. .the state’s words, verbatim · CDSS document, Aug 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 6, 2024

87506 (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on observation and record review, Licensee did not comply with the section cited above. LPA observed for R1 Appaisal and Needs Service plan was missing a signature and the Physician's report was missing a signature and date. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee states they will read and review section 87506 Resident Records and send a signed statement acknowledging they have read and understood the regulation to CCLD via email to edward.kim@dss.ca.gov by POC due date September 6, 2024.

Type of visit: Case Management - Incident

On August 26, 2024, 12:45pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Inspection visit following up on an Incident Report received on Friday August 23, 2024 by the Orange County Regional Office. LPA Kim was greeted and granted entry by House Manager (HM) Ana Santos. Assistant Administrator (AA) Gerald Dia was contacted over the phone and was not able to be at the facility. LPA Kim toured indoor and outdoor of the physical plant with HM Santos. LPA Kim did not observe any health and safety concerns. LPA conducted one (1) resident interview, four (4) staff interviews, and an audit of resident record (R1) file. No deficiencies cited during this visit. An exit interview was conducted and a copy of this report was provided to House Manager Ana Santosthe state’s words, verbatim · CDSS document, Aug 26, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. The Administrator's (Sean Manguray), Administrator's Certificate expires on January 8, 2025, LPA and staff toured the facility. The facility is a one story home with 6 bedrooms, 3 bathrooms, living room with a screened fireplace, kitchen, dining room and a two car attached garage. LPA observed the see something say something poster (PUB 475) posted in the entry way of the facility is 8 1/2 by 11 inches. LPA observed all resident rooms had the required furnishings. LPA observed all resident rooms were clean and organized. LPA observed all 3 bathrooms were clean and operational. LPA observed the ceiling light and ceiling vent fan in bathroom 1 were non-operational. Bathroom 1 had a vanity light mounted above the sink. Hot water measured 105.2 degrees Fahrenheit in all bathrooms. LPA observed a 2 day perishable and a 7 day non-perishable food supply in the kitchen. LPA observed the medications are kept locked in the garage in a tool cart. The garage is kept locked and used for storage. LPA inspected the first-aid kit. LPA observed the first aid kit did not have a current edition first aid manual. The smoke detectors/carbon monoxide detectors tested operational. LPA observed the fire extinguishers in the dining room and kitchen are fully charged. No obstacles or hazards observed inside of the facility. LPA and staff toured the backyard. There is covered patio for residents to sit outside. The exit gate is latched and self closing. No bodies of water observed in the backyard. No obstacles or hazards observed in the backyard. LPA reviewed 4 resident files. No discrepancies observed in any of the resident files. LPA reviewed all 4 resident medications. No discrepancies observed. LPA reviewed 3 staff files. No discrepancies observed. All 3 staff files reviewed had the required training. The last emergency drill was conducted on February 14, 2024. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 29, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.