306001920-1-2-2025-22-AS-EKIM-DCK2AA-20250102161312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001920
Report Date: 01/02/2025
Date Signed: 01/02/2025 04:13:29 PM

Document Has Been Signed on 01/02/2025 04:13 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/ DIRECTOR:	MIKE ADAMS		FACILITY TYPE:	740
ADDRESS:	1037 N RICHMAN AVE.		TELEPHONE:	(714) 870-5820
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Administrator Mike Adams		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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On January 2, 2025, at 9:30am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Aida Rodriguez. LPA Kim met with Administrator (AD) Mike Adams and explained the purpose of the visit.

The facility is licensed to operate for six (6) nonambulatory residents and has a hospice waiver for five (5) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a walk-in closet, living area, foyer, dining area, kitchen, outdoor covered patio, and a detached two car garage.

LPA Kim toured inside and outside of the physical plant with AD Adams. There were no bodies of water and no physical obstructions in the passageways. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be clean and operational. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and mounted in the kitchen.

Evaluation Report Continues on LIC 809-C.

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

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: ARC FACILITY AT RICHMAN	FACILITY NUMBER: 306001920
	VISIT DATE: 01/02/2025

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-870-5820) remains available.

LPA Kim conducted an audit of resident files (R1-R5), staff files (S1-S3), and medication. LPA Kim conducted one (1) staff interview.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. Technical violations were issued at the time of the visit.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Mike Adams.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/02/2025 04:13 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: 01/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed the water temperature in all three resident bathrooms measure from 134.4 degrees F to 136.5 degrees. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2025
	Plan of Correction
1 2 3 4	Licensee fixed the water temperature in all three bathrooms that measured from 109.6 degrees F to 110.6 degrees F. Licensee states they will keep a record for every 1 hour for each bathroom from January 2, 2025 5:00pm to January 3, 2025 5:00pm and send it to CCLD via email to edward.kim@dss.ca.gov by POC due date January 3, 2025.

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.

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 01/02/2025 04:13 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: 01/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed two out of five persons did not have an updated reappraisal. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	Licensee states they will send an update appraisal for Resident1 and Resident 2 to CCLD via email to edward.kim@dss.ca.gov by POC due date January 16,2025.

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.

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

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