<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000638
Report Date: 10/11/2024
Date Signed: 10/11/2024 03:38:05 PM


Document Has Been Signed on 10/11/2024 03:38 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:3K HOME CAREFACILITY NUMBER:
306000638
ADMINISTRATOR:MARIA N.G. MANIMBOFACILITY TYPE:
740
ADDRESS:700 S. PLYMOUTH PLACETELEPHONE:
(714) 774-8653
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 2DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Conrad ManimboTIME COMPLETED:
04:00 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) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA was allowed entry into the home by Staff Conrad Manimbo. Administrator Maria Manimbo arrived shortly after. AD's Certificate expires on 04/26/2025.

There are 2 Residents and 2 staff present during today's visit. LPA, along with Staff Conrad toured the physical plant. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each Resident comfortably. Bathrooms were checked, toilets/water faucets worked properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. LPA observed sharps and cleaning supplies are inaccessible to the residents. Smoke detectors and carbon monoxide detector tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked and self-latching. Backyard has a covered patio with patio furniture for outdoor activities and sufficient seating for Residents and visitors. Emergency/Fire Drill are conducted but not documented. LPA observed emergency supplies including food and water. LPA reviewed 2 Resident files and 2 staff file. Resident files contained required documentation such as health assessments and admission agreements. Staff files contained required documentation including fingerprint clearance. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately.



Based on the observations made during today’s visit, the following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report, along with Appeals Rights was discussed with the facility Administrator and a copy of this report, and LIC9102TV, were provided via email.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024
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 10/11/2024 03:38 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: 3K HOME CARE

FACILITY NUMBER: 306000638

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 due to the facility being unable to produce proof of disaster drills conducted in the last year. This poses a potential safety risk to persons in care
POC Due Date: 10/18/2024
Plan of Correction
1
2
3
4
AD stated she conducted drill last week but did not document. AD will conduct a drill and document it in a Drill log and send LPA proof of completed drill via email by the assigned POC due date of 10/18/2024. AD stated they will email LPA the completed drill documentation by the assigned POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
(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 record review, the licensee did not comply with the section cited above in which both staff employ do not have current First Aid/CPR training in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
1
2
3
4
Licensee to provide proof of valid CPR training 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.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/11/2024 03:38 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: 3K HOME CARE

FACILITY NUMBER: 306000638

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
(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 LPA's review of facility records, there is no proof of staff training in files. This could pose a potential health and safety risk to resident's in care.
POC Due Date: 10/25/2024
Plan of Correction
1
2
3
4
Licensee to provide training and provide proof of staff training by POC due date of 10/25/2024 to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3