306001429-5-22-2024-22-AS-MTEA-D5HVJC-20240522162830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001429
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:28:39 PM

Document Has Been Signed on 05/22/2024 04:28 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:	PLACERVILLE HOME CARE		FACILITY NUMBER:	306001429
ADMINISTRATOR:	MICLEA, RAMONA		FACILITY TYPE:	740
ADDRESS:	1060 FLAMINGO WAY		TELEPHONE:	(562) 477-4343
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 6	DATE:	05/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ramona Miclea		TIME COMPLETED:	04:40 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 today's date, Licensing Program Analysts (LPAs) Michael Tea and Sean Haddad conducted an unannounced Annual Required-1 year inspection visit. LPAs were granted entry by Administrator (AD) Ramona Miclea. AD Certificate for Ramona Miclea expires on 9/18/2025. This is a facility licensed for a capacity of six non-ambulatory residents which two can be on hospice. At 1:30 PM, LPA Tea and Haddad reviewed whether the following is in compliance: licensee is operating the facility within the conditions and limitations, which are specified on the license, including the capacity limitation, after corrections. The facility is a 1 story home. The home consists of: 3 private staff rooms, 4 resident bedrooms, which 2 are shared, 2 restrooms for residents and 1 bathroom for staff , 2 living rooms, kitchen with dining area, 2 car garage used for storage and supplies and a back yard. Between 1:50 PM - 2:20 PM, LPAs reviewed 2 of 2 staff records, 6 of 6 resident records. Residents files and staff files contained all required documentation. At 2:20 PM, LPA Haddad reviewed 6 of 6 client centrally stored medication records. LPAs observed medications are secured in a secured cabinet in staff room, not accessible to clients in care, after corrections. 6 of 6 Medication records were found to be within Title 22 CCR, after corrections. At 2:56 PM, LPAs along with AD Miclea conducted the tour inspection. A tour of the interior and exterior of the facility and physical plant were inspected, including but not limited to testing hot water temperature in resident and common bathrooms. The resident bathroom water tested and measured about 113.0 degrees Fahrenheit. All smoke detectors, carbon monoxide, were operational and functional. LPAs verified if facility is providing a comfortable temperature due to hot/cold weather condition. Facility has a working centralized heater and air conditioner to use for the cold or hot weather as needed. The temperature inside the facility was recorded to be 76 degrees Fahrenheit. CONTINUED ON LIC 809-C PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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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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: PLACERVILLE HOME CARE	FACILITY NUMBER: 306001429
	VISIT DATE: 05/22/2024

NARRATIVE

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LPAs reviewed facility telephone; provision of sufficient lighting; exit obstructions, if any; and potential hazards. Poisons, toxic substances, and other dangerous objects were noted to be secured in staff area and inside garage not accessible to clients in care, after corrections. Kitchen knives were stored and secured, not accessible to clients in care, after corrections.
The Outside grounds were inspected during facility tour. LPAs observed sitting area with a shaded patio. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
AD reported offering the following indoor and outdoor activities at the facility for residents such as doing puzzles, crafting bead jewelry, playing card games, and taking walks around the neighborhood, walking as far to the community pool in the neighborhood.
Two fire extinguishers observed and fully charged, and last tested on December 19, 2023. AD reports fire drills are conducted with staff and clients. Last facility fire drill was conducted on March 4, 2024.
Plentiful basic hygiene items and linen supply were available. First Aid KIT and other aide supplies were observed to be stored in secured cabinet in. Furnishing cleanliness and state of repair, and fixtures were examined. Nonskid mats were observed in resident restrooms. Operational and functional Washer and Dryer were observed in garage area.
The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Ramona Miclea and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/22/2024 04:28 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: PLACERVILLE HOME CARE	FACILITY NUMBER: 306001429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations the licensee did not insure that toxins were inaccessible in the garage and knives and suppliments were inaccessible in the kitchen, this poses an immediate safety risk to the residents in care.
	POC Due Date: 05/23/2024
	Plan of Correction
1 2 3 4	During the inspection, these items were secured and LPA confirmed. Licensee stated they will conduct staff training on securing dangerous items and submit proof to LPA by POC due date.

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents Resident #1 is bed ridden on Physical Examination Report but does not have the fire clearance for bed ridden residents. This poses an immediate safety risk to the resident in care.
	POC Due Date: 05/23/2024
	Plan of Correction
1 2 3 4	Licensee stated they will request a bedridden fire clearance 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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/22/2024 04:28 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: PLACERVILLE HOME CARE	FACILITY NUMBER: 306001429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(1)

Incidental Medical and Dental Care Services

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obsevation, Resident #1 was not given their 40 mg dose of pantoprazole this morning, which poses a potential health risk to persons in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	During the inspection, the licensee contact the resident's doctor who stated there will be no complications from giving this medication later in the day. Licensee stated they will conduct medication training and will submit proof to LPA by POC due date.

Type B

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
1 2 3 4	Based on documents the licensee does not have an emergency disaster plan, which poses a potential safety risk to residents in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	Licensee stated they will create a new 9-page LIC610E and submit it to LPA 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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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