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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803389
Report Date: 10/30/2023
Date Signed: 10/30/2023 03:26:37 PM

Document Has Been Signed on 10/30/2023 03:26 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ORANGE COMMUNITY CAREFACILITY NUMBER:
197803389
ADMINISTRATOR:SAAFIR, AHMEDFACILITY TYPE:
735
ADDRESS:2103 ORANGE AVENUETELEPHONE:
(562) 599-0856
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 36CENSUS: 23DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Ahmed SaafirTIME COMPLETED:
12:15 PM
NARRATIVE
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On 10/30/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Ahmed Saafir and explained the purpose of today’s visit. The facility is licensed to serve 34 ambulatory and 2 non-ambulatory mentally disabled adult clients with restricted health conditions ages 18-59. Current census is 23, and there are currently 0 adult clients with restricted health conditions in care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 2 separate 2 story buildings. Building #1 is equipped with the TV room, office, a room used as a pantry, dining room, kitchen, a staff restroom and 2 units on the second floor. Building #2 is equipped with 4 units between both floors and a laundry room. All units are equipped with 3 rooms and 1 bathroom. There are no bodies of water nor firearms on the property. The front yard is free of debris/hazards.

LPA conducted a records review of 3 staff records, 4 client records, and 4 medication administration records. No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 02/08/23, fire extinguisher fully charged and observed throughout the facility, carbon monoxide and smoke detectors observed and are operational. Landline and internet service was observed.

Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389
VISIT DATE: 10/30/2023
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temperature properly measured between 105-120 F.. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be stored and inaccessible to clients. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit discrepancies were observed and documented on 809 D.

Exit interview conducted with Administrator Ahmed Saafir, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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Document Has Been Signed on 10/30/2023 03:26 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/30/2023 at 11:04 AM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
85088 (c)(2) Fixtures, Furniture, Equipment and Supplies
The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.
Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.
This requirement is not met as evidenced by: Some rooms inspected were observed without a required lamp or chair.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as some rooms insoected were observed without a required lamp and/or chair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Administrator will place required furniture (chair and/or lamp) in rooms that currently do not have them by POC due date and will submit proof to LPA.
Type B
Section Cited
CCR
85088(e)(2)
85088 Fixtures, Furniture, Equipment and Supplies
Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff.
Night lights shall be maintained in hallways and passages to nonprivate bathrooms.


This requirement is not met as evidenced by: Emergency lighting was not observed during tour
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as Night lights were not observed to be maintained in hallways and passages to nonprivate bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Administrator will purchase emergency lighting/might lights and place them in the hallways/passages by POC due date and submit proof to LPA.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2023 03:26 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/30/2023 at 11:19 AM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5
85095.5 Infection Control Requirements
85095.5(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.


This requirement is not met as evidenced by: An Infection Control Plan was not observed.
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as an Infection Control Plan was not observed/ available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Administrator will create and submit to LPA an infection control plan for the facility and will submit it by POC due date.
Type B
Section Cited
CCR
80023
80023 disaster and mass casualty plan: Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by: last drill was conducted on 02/08/23
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above as the last fire drill/disaster plan was conducted more than six months ago (02/08/23) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Administrator to conduct drills and submit proof to LPA by POC 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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


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