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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001028
Report Date: 07/26/2024
Date Signed: 07/26/2024 11:34:52 AM


Document Has Been Signed on 07/26/2024 11:34 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:GOOD SAMARITAN IIFACILITY NUMBER:
306001028
ADMINISTRATOR:CAMBIO, SUSAN & LEOFACILITY TYPE:
740
ADDRESS:26852 LA SIERRATELEPHONE:
(949) 367-1228
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 3DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Leo Cambio, Administrator
Susan Cambio, Administrator		TIME COMPLETED:
11:50 PM
NARRATIVE
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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 administrators Leo and Susan Cambio.

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 a loft, two private bedrooms, two shared bedrooms and one staff room in addition to the facility's common living areas and two bathrooms, including one en-suite. All resident bedrooms have the required furnishing, bathrooms are equipped with grab bars and slip mats. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently three residents admitted to the facility with no resident receiving hospice care at the time of the visit. The current hospice waiver allows for one resident. 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. One fire extinguisher present is observed to be fully charged. LPA advised licensee to ensure annual maintenance or replacement of the fire safety equipment. Sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure, however the daily prepared medication were located in a separate drawer without a lock. Medication was reviewed for accuracy during the visit. LPA reviewed three resident files along with one staff file. One staff member on the roster was found to be background cleared but not associated to this specific licensed location.
Based on the observations made during today’s inspection, two type A deficiencies 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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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 07/26/2024 11:34 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: GOOD SAMARITAN II
FACILITY NUMBER: 306001028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interview conducted, the licensee did not comply with the section cited above as one staff member was found to not be associated to this licensed location in Guardian which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2024
Plan of Correction
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Licensee will submit a clearance transfer request and provide proof of association to LPA.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the tour of the physical plant, the licensee did not comply with the section cited above as prepared medication for the same day's lunch was found to be stored in an unlocked drawer rather than the secure central storage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2024
Plan of Correction
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Medication were placed in the secure and locked drawer during the visit. Deficiency cleared during the visit.
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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