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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803389
Report Date: 10/11/2024
Date Signed: 10/11/2024 10:58:02 AM

Document Has Been Signed on 10/11/2024 10:58 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ORANGE COMMUNITY CAREFACILITY NUMBER:
197803389
ADMINISTRATOR/
DIRECTOR:		SAAFIR, AHMEDFACILITY TYPE:
735
ADDRESS:2103 ORANGE AVENUETELEPHONE:
(562) 599-0856
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 36CENSUS: 23DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Administrator Ahmed SaafirTIME VISIT/
INSPECTION COMPLETED:
11:20 PM
NARRATIVE
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On 10/11/24 Licensing Program Analyst (LPA) 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. Administrator provided with upcoming annual fees info and pin.

The facility is a (2)-story commercial apartment building 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, all units are equipped with 3 rooms and 1 bathroom, there is an outside laundry room. 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, 4 P&I ledgers, and 4 medication administration records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 06/21/24, fire extinguisher fully charged and observed throughout the facility, carbon monoxide and smoke detectors observed and are operational. Landline and internet service was observed.

Deficiencies cited on 809D page.

Exit interview conducted with administrator, appeal rights explained and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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Document Has Been Signed on 10/11/2024 10:58 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/11/2024 at 10:31 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087Buildings and grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as the bathroom in the womens unit has broken tiles, the light bulb is haging from the ceiling and not properly installed, and the steel door for the upstairs mens unit is in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Administrator will provide proof or repair to LPA by POC due date.
Lizeth.villegas@dss.ca.gov
Type B
Section Cited
CCR
80087(c)
80087 Buildings and grounds
All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above as there are fiberglass doors located in the TV room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Administrator to remove and dispose of fiberglass doors by POC due date 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: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/11/2024 10:58 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 10/11/2024 at 10:40 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(a)
80022 Plan of operation
Each licensee shall have and maintain on file a current, written, definitive plan of operation.

Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facilty is using a MAR however the MAR is being used incorrectly. LPA observed the MAR to be missing documentation regarding medication refusals and/or medications missed as well as MAR details client received medications however medication was observed to be in the bubble pack for Clients 1 and 2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Administrator to hold an in-service regarding the importance of medication documentation and provide LPA with a copy of in-service held along with signatures of in-service participants. Proof shall be submitted to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


LIC809 (FAS) - (06/04)
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