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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001581
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:25:58 PM

Document Has Been Signed on 12/03/2024 04:25 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:AMERICAN LEGEND'S HOMEFACILITY NUMBER:
306001581
ADMINISTRATOR/
DIRECTOR:		QUINTO, ESTRELLAFACILITY TYPE:
740
ADDRESS:25746 SANTO DRIVETELEPHONE:
(949) 922-0640
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Beth Quinto, AdministratorTIME VISIT/
INSPECTION 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 this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by caregiving staff after introducing themselves and stating the purpose of the visit. Administrator Beth Quinto was notified via telephone and arrived later to assist with the inspection.

There are currently four residents in care, none of which is receiving hospice care. One admitted resident was hospitalized on the day of the visit for scheduled surgery and is absent from the premises. LPAs observed residents participating in activities in the facility’s common areas and relaxing in their respective bedrooms. LPAs accompanied by facility caregiver toured the physical plant. The facility is a one-story house with an attached garage. The facility has six private resident bedrooms and two shared bathrooms along with one staff room. All bedrooms appeared clean and sanitary. LPAs observed all the resident bedrooms have the required furnishings. One resident has half-rails in place for postural support without the appropriate physician order. Type B citation issued. All bathrooms appear clean and sanitary. Bathrooms were equipped with grab bars and non-slip mats. Hot water temperature measured slightly above the required temperature range and was adjusted down during the visit. Consultation provided on monitoring water temperature.

LPAs observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. LPA observed knives locked in a secure drawer. A fire extinguisher is verified to be charged and has been maintained in 2024. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked cabinet in the dining room. The attached garage is inaccessible to residents and is used for storage and for laundry. Cleaning supplies are located in the garage. Window cleaning solution and bleach observed unsecure in the backyard. Type B citation issued and cleared during the visit.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 5
Document Has Been Signed on 12/03/2024 04:25 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/03/2024 at 03:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMERICAN LEGEND'S HOME
FACILITY NUMBER: 306001581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observation made during the facility visit,, the licensee did not comply with the section cited above as window cleaning solution and a bottle of bleach were observed to have been left accessible in the facility's backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
Cleaning products secured during the visit. Deficiency cleared.
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
1
2
3
4
Based on record review and staff interviews, the licensee did not comply with the section cited above as no quarterly drills have been conducted in 2024, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
1
2
3
4
Licensee stated they would resume scheduling and conducting quarterly drills. Documentation to be provided to LPA before 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
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
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: AMERICAN LEGEND'S HOME
FACILITY NUMBER: 306001581
VISIT DATE: 12/03/2024
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
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC809
LPAs and caregiving staff toured the outside of the facility and observed it to be free of obstructions. LPAs observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on both sides of the property are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed four resident records and reviewed all necessary components. Medical assessments have been updated in a timely manner. LPAs reviewed resident medication records. No discrepancies were observed. LPAs reviewed two staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Infection Control and Emergency and Disaster plans were both reviewed and are complete and accurate. Fire and emergency drills are not currently conducted quarterly or documented as required. Type B citation issued.

Based on the observations made during today’s visit, three type B 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 provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/03/2024 04:26 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/03/2024 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMERICAN LEGEND'S HOME
FACILITY NUMBER: 306001581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(a) (...)Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as one resident with half rails had no physician order on file for the use of half rails for postural support. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
1
2
3
4
Licensee reached out to the resident's physician and will obtain adequate orders as soon as possible. Orders to be provided to LPA before the plan of corrections due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5