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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000176
Report Date: 07/19/2021
Date Signed: 05/05/2022 09:14:45 AM


Document Has Been Signed on 05/05/2022 09:14 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:AREVALO'S BOARD & CARE HOMEFACILITY NUMBER:
306000176
ADMINISTRATOR:AREVALO, VIOLETA D.FACILITY TYPE:
740
ADDRESS:10462 POONA DR.TELEPHONE:
(714) 774-0455
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 1DATE:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Violeta D. ArevaloTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Lydia Martinez conducted an unannounced Annual Required inspection to the facility. LPA Martinez met and was granted entry into the facility by Administrator Violeta Arevalo and the reason for the visit was explained.

Facility has a capacity of six (6), of which two (2) may be non ambulatory residents ages 60 years and over for Developmentally Disabled Adults. At 1:05 PM, LPA toured the facility with Administrator Violeta Arevalo. Facility has 1 resident in care during today's visit. LPA observed resident relaxing in common area watching TV. Resident appeared clean and happy. LPA did not observe a screening/sanitizing station in the entrance of the facility nor a a visitor sign in sheet. Administrator stated normally facility has no visitors but is aware of need to screen visitors upon entry. Facility takes resident temperatures daily. Facility has COVID precaution postings as well as all required Department postings. Administrator Arevalo has an Administrator Certificate which expired on 06/27/2021. LPA observed all certificates of completion to renew, just waiting for certificate. Facility Mitigation Plan was provided to LPA Martinez during today's visit. LPA observed ample emergency food and water as well as a First Aid kit. LPA observed a large outside visitation area with shaded area. LPA toured the kitchen area and facility has an ample supply of PPE and cleaning supplies. LPA observed resident's pre-poured medication on top of the microwave in the kitchen. LPA also observed the medication locked in hallway closet. Facility has a plan for COVID testing the resident and staff as needed as well as a plan for isolation. LPA reviewed resident's file and all contained required documentation as well as updated emergency information.

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: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
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 3


Document Has Been Signed on 05/05/2022 09:14 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: AREVALO'S BOARD & CARE HOME
FACILITY NUMBER: 306000176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


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 that LPA observed resident's pre-poured medication placed on top of the microwave in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2021
Plan of Correction
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The Administrator immediately locked away medication. Stated will read section cited and self certify understanding of section cited and submit to LPA by close of busines day of Tuesday, 7/20/201
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: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 05/05/2022 09:14 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: AREVALO'S BOARD & CARE HOME
FACILITY NUMBER: 306000176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(D)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview with resident, the licensee did not comply with the section cited above in that LPA observed disposable bed pads cut up into squared pieces in the dining room and in the resident's bathroom . The cut up bed pad pieces are used as toilet paper per resident. LPA observed toilet paper in both staff bathrooms and only resident's bathroom had the bed pad pieces. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2021
Plan of Correction
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Licensee states they will remove bed pad pieces from resident's bathroom and replace with toilet paper.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3