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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306001920
Report Date:
01/29/2024
Date Signed:
01/29/2024 12:37:37 PM
Document Has Been Signed on
01/29/2024 12:37 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:
ARC FACILITY AT RICHMAN
FACILITY NUMBER:
306001920
ADMINISTRATOR:
MIKE ADAMS
FACILITY TYPE:
740
ADDRESS:
1037 N RICHMAN AVE.
TELEPHONE:
(714) 870-5820
CITY:
FULLERTON
STATE:
CA
ZIP CODE:
92835
CAPACITY:
6
CENSUS:
6
DATE:
01/29/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:55 AM
MET WITH:
Lourdes Manunay
TIME COMPLETED:
12:51 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA spoke with Administrator/Licensee Mike Adams and informed him of the visit. Mike Adams stated he could not be present for the visit but would be available to answer any questions. LPA and staff toured the facility. LPA observed all resident bedrooms were clean and had the required furnishings. All smoke detectors/carbon monoxide detectors tested operational. LPA observed all 3 bathrooms were clean and operational. Hot water measured 120.0 degrees Fahrenheit in all three bathrooms. LPA observed the kitchen stove top cannot light unassisted. LPA observed the stove top and the vent above the stove top are not clean and have visible grease stains. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the knives are kept locked in a cabinet. LPA observed the medications are kept locked in a cabinet in the laundry room. LPA observed the cleaning supplies are kept locked in the laundry room. LPA observed the fireplace in the living is screened. LPA observed the PUB 475 see something say something poster is not posted in the entry way of the facility is not by 20" by 26" inches. LPA toured the backyard and garage. LPA observed the garage has beds and personal items next to the beds. LPA observed old furniture, boxes, wood, wheelchairs, walkers and chairs stored on the side of the garage and in the outdoor patio. The exit door from the backyard is latched and operational. LPA reviewed 6 out of 6 resident files. No discrepancies observed. LPA reviewed 2 staff files. LPA observed only 6 hours of training for both staff members and no CPR training for either staff member. LPA reviewed 6 out of 6 resident medications, no discrepancies observed. Deficiencies are being cited per Title 22 division 6 of the California Code of regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
01/29/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/29/2024
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
6
Document Has Been Signed on
01/29/2024 12:37 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:
ARC FACILITY AT RICHMAN
FACILITY NUMBER:
306001920
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(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
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4
Based on record review, the licensee did not comply with the section cited above, 2 out of 2 staff members reviewed did not have current CPR training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/06/2024
Plan of Correction
1
2
3
4
Licensee agrees to have all staff trained in CPR by the POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
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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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
01/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/29/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
01/29/2024 12:37 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:
ARC FACILITY AT RICHMAN
FACILITY NUMBER:
306001920
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the kitchen stove top cannot light unassisted and stove top and vent above are not clean. There is visible grease on the stove top and vent above the stove top, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/06/2024
Plan of Correction
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Licensee agrees to clean the stove top and the vent above the stove top and to repair or replace the stove top so it lights unassisted.
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation the licensee did not comply with the section cited above. LPA observed there were two beds in the garage and personal belongings next to the beds. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/06/2024
Plan of Correction
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3
4
Licensee agrees to remove the beds and personal belongings from the garage and to not use the garage as a bedroom for anyone.
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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
01/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/29/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
01/29/2024 12:37 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:
ARC FACILITY AT RICHMAN
FACILITY NUMBER:
306001920
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(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
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2
3
4
Based on record review, the licensee did not comply with the section cited above. In 2 out of 2 staff files reviewed, each staff member only had 6 hours of training. Which poses a potential health and safety risk to persons in care.
POC Due Date:
02/13/2024
Plan of Correction
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4
Licensee agrees to have the 2 staff members complete the annual training, CPR training and have it properly documented.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
01/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/29/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6