300606338-3-28-2022-22-AS-RQUZ-CCXRD6-20220328125524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300606338
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:56:26 PM

Document Has Been Signed on 03/28/2022 12:56 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BALBOA ISLAND BOARD & CARE		FACILITY NUMBER:	300606338
ADMINISTRATOR:	BARTON, CYNTHIA G.		FACILITY TYPE:	740
ADDRESS:	300 APOLENA		TELEPHONE:	(949) 673-8589
CITY:	BALBOA ISLAND	STATE: CA	ZIP CODE:	92662
CAPACITY:	4	CENSUS: 1	DATE:	03/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Patrick Guillemer, Caregiver, Rose Breton, Caregiver and Cynthia Barton, Administrator (Via Telephone)		TIME COMPLETED:	01:10 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by caregiver Patrick Guillemer. During today's visit, LPA Quiroz called Licensee/Administrator (L/AD) Cynthia Barton introduced self and discussed purpose of the call. Caregiver Rose Breton arrived to facility on or about 11:08am. L/AD Cynthia Barton arrived to facility on or about 12:00pm.

This facility is licensed to provide services to 4 Non-Ambulatory residents. (L/AD) Cynthia Barton has an Administrator Certificate with expiration date of 1/14/2022. L/AD Cynthia Barton indicated "Hoping to complete by April 15, 2022 due to COVID-19."

On or about 11:12am, LPA Quiroz reviewed 1 of 1 resident records.

On or about 11:25am, LPA Quiroz along with Caregiver Rose Breton toured the inside and outside of the facility. There is one (1)resident in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed one (1) resident in living room resting interacting with staff. One of One resident present in the facility appeared to be clean and well taken care of. LPA Quiroz did not observe required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz did not observe a COVID-19 check in station in the main entry of the facility. LPA Quiroz inquired about visitor sign in sheet/Log and COVID-19 screening check in station, Caregiver Rose Breton indicated "We don't have a thermometer and we don't have a visitor sign in sheet/ log either."

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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 03/28/2022 04:43 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/28/2022 04:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BALBOA ISLAND BOARD & CARE	FACILITY NUMBER: 300606338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	87705 :Care of Persons with Dementia (f)(1)(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidence by: Kitchen cabinet where knives are kept locked was unlocked. Caregiver Rose Breton indicated "It's broken, doesn't work." This poses an immediate risk to residents in care.
	POC Due Date: 04/01/2022
	Plan of Correction
1 2 3 4	On today's date at 11:28am, Caregiver Rose Breton removed kitchen knives from kitchen cabinet not working and placed the knives in secured cabinet where medications are securely being stored. L/AD Cynthia Barton will have kitchen cabinet door repaired and submit proof of repair to LPA Quiroz by 4/1/2022.

Type A

Section Cited

CCR

87303(2)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	87303 Maintenance and Operation (2)Faucets used by residents for personal care...not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidence by: At 12:10pm, LPA Quiroz recorded water temperature to be 139.1 in resident hallway restroom. L/AD Barton indicated "I knew it was high, it's a new heater. I will call plumber and schedule him to bring water temperature down." This poses an immediate risk to residents in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	On today's date at 12:17pm, L/AD Cynthia Barton called Plumber and scheduled appointment to bring down facility water temperature down. L/AD Cynthia Barton will record water temperature for 7 consecutive days and submit proof of repair to LPA Quiroz by 4/8/2022.

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BALBOA ISLAND BOARD & CARE	FACILITY NUMBER: 300606338
	VISIT DATE: 03/28/2022

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Caregiver Patrick Guillemer indicated facility is taking temperatures daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz observed ample seating area with table and chairs for resident’s enjoyment in front porch area.

Facility has completed the LIC 808 Mitigation plan dated 7/08/2021. The LIC 808 Mitigation Plan pending review at this time. L/AD Cynthia Barton indicated, "Need to print it out and place a copy at facility."

During today's inspection visit, Caregiver Rose Breton indicated "All staff and resident are fully vaccinated and have received booster for COVID-19."

Based on the observation made during today’s visit, deficiencies were noted during today's visit per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with L/AD Cynthia Barton, and a copy of this report, LIC 809-D, Appeal Rights and LIC 811 were provided to L/AD Cynthia Barton via email.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC809 (FAS) - (06/04)

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