300611827-3-24-2022-22-AS-PVEZ-CCTQZX-20220324123729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300611827
Report Date: 03/24/2022
Date Signed: 03/24/2022 12:37:37 PM

Document Has Been Signed on 03/24/2022 12:37 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:	SONIA'S CARE HOME		FACILITY NUMBER:	300611827
ADMINISTRATOR:	PEREZ, MANUEL		FACILITY TYPE:	740
ADDRESS:	292 HANOVER DRIVE		TELEPHONE:	(714) 662-0637
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 5	DATE:	03/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Manuel Perez - Administrator		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Sonia's Care Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Daysi Guzman. Administrator (AD) Manuel Perez was also present. The facility is licensed for 6 non-ambulatory residents. There are currently 5 residents living in the facility. AD Perez indicated one resident was in the hospital. LPA Velazquez then requested a copy of the Serious Incident Report (SIR) LIC 624 and AD Perez indicated he was not aware he had to submit an SIR to Licensing when a resident is hospitalized. The last emergency disaster drill was conducted on March 19, 2022. At 10:27 AM LPA Velazquez conducted a tour of the physical plant along with AD Perez. The 1 story home consists of 5 resident bedrooms with 2 bathrooms. There is 1 staff bedroom with 1 staff bathroom. The facility also has 2 living rooms, dining area, and kitchen. The 5 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed a postural support bar on two of the resident beds. AD Perez indicated he did not have a written physician's order for the postural support bar for the 2 residents. LPA and AD observed a sliding glass door in one of the living rooms did not have an auditory alarm and the facility has residents with Dementia. AD verified the sliding glass door did not have an auditory alarm pursuant to Title 22 regulation. During the visit an auditory alarm was purchased and installed which LPA Velazquez verified. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

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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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: SONIA'S CARE HOME	FACILITY NUMBER: 300611827
	VISIT DATE: 03/24/2022

NARRATIVE

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LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 116.2 degrees Fahrenheit in the left sink and at 116.7 degrees Fahrenheit in the right sink of the first bathroom and at 115.3 degrees Fahrenheit in the second bathroom which AD Perez verified.

LPA Velazquez inspected the kitchen along with AD Perez. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Toxins and sharps were locked and inaccessible to residents. First Aid kit was checked and found to be in order. The facility did have a First Aid guide.

LPA Velazquez along with AD Perez toured the outside grounds. There was shading and sufficient seating for residents. LPA and AD also observed a piece of wooden fencing with nails jutting out which AD Perez verified. AD indicated he would remove the wooden fencing that was lying on the ground. Walkways around the home were clear of hazards and the exit gates were operational. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit but LPA did verify 2 of the 6 residents in the facility were diagnosed with Dementia which AD verified. LPA Velazquez informed AD Perez to ensure a written physician's order for the Postural Support Bars is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports. LPA also reviewed and provided a copy of Title 22 regulation Section 87211 Reporting Requirements. AD Perez acknowledged receiving a copy of said regulation.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Manuel Perez and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/24/2022 12:37 PM - 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: SONIA'S CARE HOME	FACILITY NUMBER: 300611827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(3)

87608(a)(3) Postural Supports. Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from the physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2022
	Plan of Correction
1 2 3 4	Licensee to obtain written physician's orders for the postural supports for the 2 residents that have postural supports without a written physician's order. Licensee to submit written proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/24/2022 12:37 PM - 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: SONIA'S CARE HOME	FACILITY NUMBER: 300611827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)(D)

87211(a)(1)(D) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of the event; attending physician's name, findings, and treatment, if any; and disposiition of the case. (D) Any incident which threatens the welfare, safety, or health of any resident, such as psychological abuse by staff or other residents, or unexplained absence of any resident.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee was not aware they had to submit a written report to licensing regarding a resident's hospitalization.
	POC Due Date: 03/25/2022
	Plan of Correction
1 2 3 4	Licensee will submit an LIC 624 report to the Orange RO email address which LPA provided to the licensee 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC809 (FAS) - (06/04)

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