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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001989
Report Date: 08/02/2024
Date Signed: 08/02/2024 04:17:13 PM

Document Has Been Signed on 08/02/2024 04:17 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARING VILLAGEFACILITY NUMBER:
306001989
ADMINISTRATOR/
DIRECTOR:
MICHELLE DOMINGOFACILITY TYPE:
735
ADDRESS:8912 W. KATELLATELEPHONE:
(714) 484-6524
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 49CENSUS: 46DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Michelle Domingo - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Alicia Domingo, Caregiver/Activity Assistant. LPA met with Administrator Michelle Domingo and explained the purpose of the inspection.

The facility is one-story with two buildings. The facility has twenty-six resident bedrooms, four common bathrooms, kitchen, dining room, office, medication room, laundry room, living room, courtyard and outdoor lounge space. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. LPA noted clients were lounging or participating in karaoke in the courtyard.

All client rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for clients in the hallway closets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPA observed the fire extinguisher was last serviced on May 1, 2024. LPA reviewed an invoice for the facility's smoke alarm/carbon monoxide/sprinkler system stating these items were serviced on 7/10/2024. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and a closet in the laundry room. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in the medication room. The courtyard and outdoor seating areas have shaded sitting/lounging areas. Exit gates are unlocked. LPA observed exit gates to be unobstructed. Based on record review, LPA determined the facility conducted one documented disaster drill in the last year. A citation is being issued. LPA reviewed three client files and four staff files. LPA also reviewed medication for three clients. LPA interviewed one staff and two clients.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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Document Has Been Signed on 08/02/2024 04:17 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 08/02/2024 at 03:31 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: CARING VILLAGE

FACILITY NUMBER: 306001989

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in due to the facility records noting only one disaster drill was conducted and documented in the last year. This poses a potential safety risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Administrator (AD) stated they will conduct their next quarterly drill, document it and email proof of drill conducted to LPA by the assigned POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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