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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000332
Report Date: 03/27/2024
Date Signed: 03/27/2024 11:47:49 AM


Document Has Been Signed on 03/27/2024 11:47 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PILGRIM'S FAITH CARE HOMEFACILITY NUMBER:
306000332
ADMINISTRATOR:VIVIAN JONAH S. RUEDASFACILITY TYPE:
740
ADDRESS:8380 MONTANA AVENUETELEPHONE:
(714) 562-0190
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: 4DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Vivien Ruedas - AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of
conducting a required annual inspection. LPA was greeted and granted entry into facility by Administrator (AD) Vivien Ruedas.

The facility is a one-story home with four client bedrooms, one client bathroom, kitchen, dining room, living room, staff room with staff bathroom, backyard and attached 2-car garage. Facility appears clean, safe and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. One client room's light was not working. AD stated an electrician began work on the light the week prior to the LPA's visit. AD stated the electrician would be back out the upcoming weekend to continue working on the resident's light. Facility has extra linens for clients in the hallway closet. Restroom is stocked with soap and paper towels and has hand-washing postings. Hot water measured at 114.8 degrees Fahrenheit in the client bathroom. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced in May of 2023. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen and the garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the kitchen. The backyard has a shaded sitting/lounging areas. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed. LPA reviewed all four client files and the staff files. LPA interviewed one staff and one resident.

Based on record review, LPA determined the facility does not have a record of an Emergency Disaster Plan, drills conducted in the last year or a current CPR certification for any staff.

Based on today's inspection four deficiencies are being issued. An exit interview was conducted with the Administrator and a copy of this report, deficiency pages and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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 03/27/2024 11:47 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: PILGRIM'S FAITH CARE HOME
FACILITY NUMBER: 306000332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to being unable to produce an Emergency Disaster Plan at the time of inspection. This poses an immediate safety risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Administrator stated they will send to the LPA via email or phone proof of the facility's completed Emergency Disaster Plan by the end of the day on 3/28/24.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(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 in one instance of scissors being left on a resident's dresser. This poses an immediate safety risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Administrator removed the scissors at the time of the inspection. LPA observed the scissors to be locked up along with other sharp objects away from resident access.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/27/2024 11:47 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: PILGRIM'S FAITH CARE HOME
FACILITY NUMBER: 306000332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in any of the personnel files which poses a potential safety risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Administrator stated they will complete CPR training and send LPA proof of completion via email or phone by the assigned POC due date of 4/10/24.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to being unable to produce proof of disaster drills conducted. This poses a otential safety risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Administrator stated they will conduct a disaster drill and send LPA via email or phone proof of completed disaster drill by the assigned POC due date of 4/10/24.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3