300613124-12-26-2024-22-AS-WVAS-DCBUCU-20241226142831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613124
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:30:26 PM

Document Has Been Signed on 12/26/2024 02:30 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ORAVILLA GUEST HOME		FACILITY NUMBER:	300613124
ADMINISTRATOR/ DIRECTOR:	WALLACE, EVELYN		FACILITY TYPE:	740
ADDRESS:	2906 E HOOVER		TELEPHONE:	(714) 639-1465
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	12/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:47 AM
MET WITH:	Nonie Arceo		TIME VISIT/ INSPECTION COMPLETED:	02:45 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	On 12/26/2024 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of completing an annual inspection. Upon Arrival LPA Vanegas was greeted and granted entrance to the facility by Caregiver Nonie Arceo. LPA Vanegas set up equipment and began a tour of the facility at 8:55AM and observed the following. This is a one storied home with five bedrooms one of which is a staff bedroom and four of which are resident bedrooms, three bathrooms, and one attached two car garage. LPA observed the facility kitchen to be clean and free of debris. LPA observed a microwave, gas stove, and dishwasher that were all tested and tested operational. Refrigerator was observed to have sufficient food for a two day supply of perishable food and a 7 day supply of non-perishable food was observed to be in the garage with sufficient emergency water. Resident's were observed to be in common areas watching television and in their respective private areas resting. Resident bedrooms were observed to have the required furnishings such as a lamp, chest drawers, bed, screened windows, a chair, and linens that are in good repair, meaning no strains or tears. Smoke detectors and carbon monoxide detectors were observed to be operational. Fire extinguisher was observed to be fully charged however did not have a fire tag on it. Resident restrooms were observed to be clean and free of mildew and debris. Water faucet and toilets tested operational, and water temperature tested at 106.7 degrees F-108.3 degrees F. Resident Showers were observed to have functional grab bars and slip resistant matts. LPA Vanegas conducted a tour of the outside of the facility and observed the following. There are no obstructions in front of any emergency exit doors. Doors have a self closing latch and are not locked. There is an outdoor seating area that is shaded for residence convenience CONTINUED ON LIC809C

Armando J Lucero	TELEPHONE: (714) 703-2866
William Vanegas	TELEPHONE: (714) 497-7621
	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

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 12/26/2024 02:30 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ORAVILLA GUEST HOME	FACILITY NUMBER: 300613124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 as licensee stated they do not have liabilirty insurance at the moment due to being sued, however she is waiting to hear back from her broker. This poses a potential safety risk to persons in care.
	POC Due Date: 01/02/2025
	Plan of Correction
1 2 3 4	Licensee will obtain a new insurance policy by POC due date and email proof of correction via email to LPA by POC due date.

Section Cited

Personnel Records

(b) Personnel records shall be maintained for all volunteers and shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as Licensee did not have a staff record for administrator which poses potential safety risk to persons in care.
	POC Due Date: 01/09/2025
	Plan of Correction
1 2 3 4	Licensee will create a file for administrator and have all the required documents inserted in the file. Licensee will submit proof of correction to LPA via email 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.

Armando J Lucero	TELEPHONE: (714) 703-2866
William Vanegas	TELEPHONE: (714) 497-7621
	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/26/2024 02:30 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ORAVILLA GUEST HOME	FACILITY NUMBER: 300613124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 two staff records not having documentation of annual training which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/09/2025
	Plan of Correction
1 2 3 4	Licensee is going to train staff and document it on her updated training log as well as give them a test on the training. LIcensee will submit proof of correction to LPA via email by POC due date.

Section Cited

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in two of four resident's medication records not being accurate which poses a potential health risk to persons in care.
	POC Due Date: 01/09/2025
	Plan of Correction
1 2 3 4	Licensee agrees to use MAR and document refusal and acceptance of medication on date and time it was administered. Licensee will submit proof of correction to LPA via email 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.

Armando J Lucero	TELEPHONE: (714) 703-2866
William Vanegas	TELEPHONE: (714) 497-7621
	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ORAVILLA GUEST HOME	FACILITY NUMBER: 300613124
	VISIT DATE: 12/26/2024

NARRATIVE

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LPA Vanegas reviewed staff files and observed that there was no staff file for the administrator that was ever assembled and they did not have any files documented for administrator a deficiency was cited on today's date. LPA Vanegas observed licensee to not have liability insurance available for review and licensee advised that they are in the process of obtaining a new policy in this moment. A deficiency was cited on today's date.
LPA Vanegas reviewed four resident files, and two staff files. All staff files did not have any of the required training that is needed annually, and it was not documented a deficiency was cited on today's date. LPA Vanegas observed all resident files to have required documents and no deficiency was cited on today's date.

LPA Vanegas reviewed medications with Caregiver Nonie Arceo and observed the following. There are some medications that are not being documented when given to the resident's, and if resident refuses the medication it is not being documented and reported to community care licensing via incident report. Licensee was made aware of the process on reporting a refusal of medication and a deficiency was cited on today's date.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: William Vanegas	TELEPHONE: (714) 497-7621
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

LIC809 (FAS) - (06/04)

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