300605409-12-18-2023-22-AS-DLMN-CYMRC5-20231218115346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300605409
Report Date: 12/18/2023
Date Signed: 12/18/2023 11:54:08 AM

Document Has Been Signed on 12/18/2023 11:54 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SUTTON FOUNDATION		FACILITY NUMBER:	300605409
ADMINISTRATOR:	JORGE G. MONROY		FACILITY TYPE:	735
ADDRESS:	4101 BELVEDERE		TELEPHONE:	(949) 651-0778
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY: 6		CENSUS: 6	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Jorge Gonzalez, Administrator		TIME COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Jorge Gonzales. Administrator Jorge Gonzalez, joined the inspection during the tour.

The facility is a one-story home with four bedrooms, two bathrooms, kitchen, dining room, living room, staff office, backyard and attached 2-car garage. LPA observed residents to be away at day program. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water initially measured below 105 degrees Fahrenheit. AD and staff adjusted the hot water heater and LPA waited approximately twenty minutes to check water temperatures again. Hot water measured at 107.9 degrees Fahrenheit in the common bathroom and 113 degrees Fahrenheit in the shared room bathroom. LPA determined through staff interview that staff use the shared bedroom bathroom, meaning the staff have to use the shared bedroom as a passageway. LPA advised staff to use the common area bathroom. A deficiency is being given on this day. LPA observed facility has emergency food and water supply. Medication for each resident is kept locked in cabinets in the staff office. The backyard has a side patio and two seating areas. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed. LPA reviewed three of the six residents files, three personnel files and the P&I. LPA observed the P&I ledger to be inaccurate for one client and the P&I money amount to be incorrect for one client. AD corrected the inaccuracies during the inspection. A deficiency is being given on this day. Smoke and Carbon Monoxide detectors tested operational. Fire Extinguishers were fully charged as indicated by the arrow pointing in the green zone. Service tags indicate Extinguishers were serviced on 7/12/2023.

Two deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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 12/18/2023 11:54 AM - It Cannot Be Edited

Created By: Dwayne L Mason On 12/18/2023 at 10:45 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUTTON FOUNDATION	FACILITY NUMBER: 300605409
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087(a)(4)

Building and Grounds

(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with staff, the LPA determined that staff use the shared bedroom as a passageway to use the bathroom located in there.The licensee did not comply with the section cited above due to the fact that a client bedroom is being used as a passageway which posesa potential personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator stated they wil notify staff at the facility to use the common bathroom and that only the clients residing in the shared room with a bathroom are permitted to use the bathroom in the shared room in the facility. AD stated they will notify the staff in person and electronically via email. AD will also post a note visible to staff in the facility. AD stated they will forward the email sent to the staff to the LPA by the assigned POC due date of 12/22/2023.

Type B

Section Cited

CCR

80026(h)

Safeguards for Cash Resources, Personal Property and Valuables. Each licensee shall maintain accurate records of accounts of client cash resources, personal property valuables entrusted to his/her care This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of four Client P&I records. One client's ledger was not updated after the most recent expense. Another client's P&I was short by $50. This poses a potential personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator corrected the ledger and deposited $50 into the appropriate client P&I files. LPA verified the accuracy of the corrections made during annual inspection. AD stated they will write up a plan that designates a second staff member who will help to ensure clients can access their money as needed and the ledger will be updated as transactions occur. AD stated they will send the written plan to LPA via email by the assigned POC due date of 12/22/2023.

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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