300613239-9-27-2024-22-AS-RMRT-D9HSAL-20240927134227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613239
Report Date: 09/19/2024
Date Signed: 09/27/2024 01:43:20 PM

Document Has Been Signed on 09/27/2024 01:43 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:	ACCENT ON SENIORS		FACILITY NUMBER:	300613239
ADMINISTRATOR:	SHARON WILLIAMS		FACILITY TYPE:	740
ADDRESS:	273 VIA BALLENA		TELEPHONE:	(949) 361-2093
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92672
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Sharon "Shay" Williams, Administrator		TIME COMPLETED:	12:00 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) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 9:15 AM. During today’s visit, LPA met with Sharon "Shay" Williams, Administrator. The facility is a single story building with six private bedrooms and an approved fire clearance of six non ambulatory residents, of which two may be on hospice. The facility currently has a census of six residents in care. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of four resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 109.4 and 110.6 degrees Fahrenheit and all smoke detectors were operational. LPA observed two residents watching television in the living room and one resident eating breakfast. The fire extinguisher is charged and was serviced on July 29, 2024. The facility’s last fire drill was conducted on May 14, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. The First Aid kit is complete with the required items. Per review medications are being given as prescribed. LPA reviewed five of five staff training and fingerprint records and a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on February 1, 2026. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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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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: ACCENT ON SENIORS	FACILITY NUMBER: 300613239
	VISIT DATE: 09/19/2024

NARRATIVE

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(Continued from LIC 809)

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Sharon "Shay" Williams, Van Ray Lasquite and Kathryn Belmonte Alano, Administrators and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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