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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
300611830
Report Date:
05/24/2022
Date Signed:
05/25/2022 07:56:08 AM
Document Has Been Signed on
05/25/2022 07:56 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:
CAMBRIDGE HOUSE
FACILITY NUMBER:
300611830
ADMINISTRATOR:
EVELYN WALLACE
FACILITY TYPE:
740
ADDRESS:
1895 NORTH CAMBRIDGE
TELEPHONE:
(714) 637-3911
CITY:
ORANGE
STATE:
CA
ZIP CODE:
92865
CAPACITY:
6
CENSUS:
5
DATE:
05/24/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:05 AM
MET WITH:
Irene Shields- Caregiver, Evelyn Wallace- Administrator
TIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Irene Shields and explained the reason for the visit. At 9:35 AM Administrator Evelyn Wallace arrived during the visit.
At 9:10 AM, LPA toured the facility. Facility is 5 bedroom, 3 bathroom single story home with a detached garage. Facility has 5 residents present during today's visit. LPA observed residents relaxing in the facility and in their respective rooms. LPA Mendivil observed postural supports on 5 out of 7 beds. All residents rooms had the required elements as well as restrooms stocked with soap. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes residents temperatures daily and documents. The facility mitigation plan has been completed and approved. LPA observed emergency food and did not observe emergency water. LPA observed unsecured prescription medication in kitchen cabinet for new resident. LPA observed locked medication cabinet.LPA observed unlocked knives in a drawer in kitchen and unsecured cleaning supplies under sink and above washer and dryer. LPA toured the outside grounds and observed outside shaded visitation area. Exit gate is unlocked and self latching. Exit gate is blocked by trash cans and discarded furniture. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation .LPA observed one pack of masks for facility. LPA reviewed all residents files and all contained required documentation including updated emergency information. All staff and residents are vaccinated for Covid 19.
Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
5
Document Has Been Signed on
05/25/2022 07:56 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:
CAMBRIDGE HOUSE
FACILITY NUMBER:
300611830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
(a) 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 a 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.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 7 beds. LPA observed postural supports without physician's orders which poses an immediate health and safety risk to persons in care.
POC Due Date:
05/25/2022
Plan of Correction
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Licensee to remove postural supports and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(h)(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 the licensee did not comply with the section cited above. LPA observed unlocked medications in kitchen cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date:
05/25/2022
Plan of Correction
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Licensee corrected during visit.
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) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2022
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
05/25/2022 07:56 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:
CAMBRIDGE HOUSE
FACILITY NUMBER:
300611830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed unsecured knives in unlocked kitched drawer which poses an immediate health and safety risk to persons in care.
POC Due Date:
05/25/2022
Plan of Correction
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Licensee to secure knvies and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inacessible to residents with Dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed unsecured clearning supplies under kitchen sink and above washer and dryer which poses an immediate health and safety risk to persons in care.
POC Due Date:
05/25/2022
Plan of Correction
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Licensee to secure cleaning supplies and provide 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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2022
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
05/25/2022 07:56 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:
CAMBRIDGE HOUSE
FACILITY NUMBER:
300611830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(a)(2)
Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure... including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed lack of emergency water which poses an immediate health and safety risk to persons in care.
POC Due Date:
05/25/2022
Plan of Correction
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Licensee to purchase water and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87307(d)(6)
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed trash cans and discarded furniture which poses an immediate health and safety risk to persons in care.
POC Due Date:
05/25/2022
Plan of Correction
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Licensee to remove trash from side of house and forward 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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2022
LIC809
(FAS) - (06/04)
Page:
5
of
5
Document Has Been Signed on
05/25/2022 07:56 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:
CAMBRIDGE HOUSE
FACILITY NUMBER:
300611830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(2)
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall;
(2) request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review the licensee did not comply with the section cited above. LPA observed an unassociated staff member which poses an immediate health and safety risk to persons in care.
POC Due Date:
05/25/2022
Plan of Correction
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Licensee to fax LIC 9128, LIC 508 and CA driver license to regional office for association by POC due date
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2022
LIC809
(FAS) - (06/04)
Page:
4
of
5