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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607294
Report Date: 10/11/2023
Date Signed: 10/11/2023 11:53:16 AM


Document Has Been Signed on 10/11/2023 11:53 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:C & A BOARD AND CAREFACILITY NUMBER:
300607294
ADMINISTRATOR:PULIDO, CARMENZAFACILITY TYPE:
740
ADDRESS:25241 ERICSON WAYTELEPHONE:
(949) 859-3162
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 3DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Alphonso PulidoTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Licensee Alphonso Pulido and explained the purpose of the inspection. During the inspection LPA and Licensee conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a two-story home with three client bedrooms and two bathrooms on the first floor. The second floor is used solely as staff quarters. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. The back yard has a shaded sitting area. LPA observed two clients present, an additional client was away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 119.8 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Medication cabinet lock was observed to be inoperable, and medication is accessible; a Deficiency was cited on today’s date. Record review of disaster drill log indicated last disaster drill was conducted in December 2022. Per Licensee, drills are conducted quarterly, however, not documented; a Technical Advisory was issued on today’s date. LPA reviewed three client files and three staff files. LPA interviewed clients and staff present.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Administrator (AD) Claudia Pulido arrived at 11:30 a.m. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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 10/11/2023 11:53 AM - It Cannot Be Edited

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: C & A BOARD AND CARE
FACILITY NUMBER: 300607294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as medication cabinet lock was observed to be inoperable, leaving centrally stored medicines unlocked and accessible, which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
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AD stated lock on medication cabinet would be replaced and checked periodically to ensure it stays in operation. AD will provided LPA with proof of POC via email
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
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