306000629-8-9-2024-22-AS-KSGH-D7YQ6N-20240809115348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000629
Report Date: 08/09/2024
Date Signed: 08/09/2024 11:54:16 AM

Document Has Been Signed on 08/09/2024 11:54 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CUDDLE CARE HOME		FACILITY NUMBER:	306000629
ADMINISTRATOR:	NELLIE MAE CAUDLE		FACILITY TYPE:	740
ADDRESS:	416 E. CHESTNUT AVE.		TELEPHONE:	(714) 282-8951
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	5	CENSUS: 2	DATE:	08/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Nellie Mae Caudle, 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility administrator Nellie Mae Caudle after introducing himself and stating the reason of the visit. During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one story home with four private bedrooms and one staff room in addition to the facility's common living areas and two bathrooms, one of which is en-suite. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. Postural supports observed in one room and physician orders verified to be on file. There are currently two residents admitted to the facility with one receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire drills are conducted quarterly. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed two resident files and two staff files. One resident and one staff interview were conducted during the visit. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 08/09/2024 11:54 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CUDDLE CARE HOME	FACILITY NUMBER: 306000629
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

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 interview and record review, the licensee did not comply with the section cited above as it was stated that the liability insurance was left to lapse. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated they would renew their liability coverage in order for coverage to resume. Documentation will be provided to the Department before the plan of correction's due date.

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
1 2 3 4	Based on interview with the licensee and record review, the licensee did not comply with the section cited above as both the administrator and one facility caregiver had lapsed CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Staff CPR training will be updated and documented prior to the plan of corrections' 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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: CUDDLE CARE HOME	FACILITY NUMBER: 306000629
	VISIT DATE: 08/09/2024

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CONTINUED FROM FORM LIC809

Based on staff records reviewed and interview with the administrator, it was confirmed that the cardio-pulmonary resuscitation training for both employees had lapsed and will need to be renewed. The facility's professional liability insurance is also stated to have lapsed and will need to be renewed. One admission agreement reviewed was found to be missing the resident's signature and was signed during the present visit.

Based on the observations made during today’s inspection, two type B deficiencies and one technical assistance advisory note 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 along with appeal rights was left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

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