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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001818
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:17:20 PM


Document Has Been Signed on 08/25/2022 12:17 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:D'BEST CAREFACILITY NUMBER:
306001818
ADMINISTRATOR:MA DINAH DELA CRUZFACILITY TYPE:
740
ADDRESS:3608 W. ASH AVENUETELEPHONE:
(714) 278-0528
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 4DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:TIME COMPLETED:
12:30 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) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by staff Lucille Nofies and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection.

A single resident was eating at the dining table, LPA observed and took picture of medication on dining table that was left unattended. LPA asked the resident if the medication was theirs, resident stated “oh, no. I’ve already had mine”; a Deficiency was cited on today’s date.

Administrator (AD) Maria Semcheshen arrived at 10:40 a.m. During the inspection LPA Gutierrez and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a single-story house with five bedrooms, and two bathrooms, with two bedrooms being occupied by staff. During the inspection LPA observed one staff and four residents in care. Residents were observed resting in their respective rooms and in the common area. A 2-day supply of perishable and a 7-day supply of non-perishable food was observed during today’s visit. Upon record review LPA noted emergency care requirements were met. LPA observed the facility does not have a 30-day supply of PPE on hand; a Technical Advisory was given on this date. Under the patio in the back of the house LPA observed storage bins stacked to the ceiling, different bags and boxes also stacked on top of one another, and a washer with tape on the front of the door and a piece of tubing inside. On the side of the home an empty television box, a toilet, a table with dust laying on its side, empty water bottles, a 5-gallon industrial bucket, and different pieces of cardboard were all observed; a Deficiency was cited on today’s date.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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 7


Document Has Been Signed on 08/25/2022 12:17 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: D'BEST CARE
FACILITY NUMBER: 306001818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)

87465 Incidental Medical and dental care.. (h)(2) Centrall stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview licensee did not store medicines in a safe and locked place that is not accessible to persons other than employess which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
1
2
3
4
Staff took medication and gave to designated resident. AD stated medication would not be placed on dining table and would immediately be given to designated resident in the future.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 08/25/2022 12:17 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: D'BEST CARE
FACILITY NUMBER: 306001818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintanance and Operation (a) The facility shall be clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview the licensse did not maintain the facility clean, sanitary, and in good repair, which poses a potential health risk to persons in care.
POC Due Date: 09/25/2022
Plan of Correction
1
2
3
4
AD stated they will be removing all items and transporting them to the city dumpster. AD will provide LPA with pictures of the patio and side of house free of debri via email by POC 9/25/2022.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: D'BEST CARE
FACILITY NUMBER: 306001818
VISIT DATE: 08/25/2022
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
LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, two 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 was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7