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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002065
Report Date: 07/01/2024
Date Signed: 07/01/2024 11:43:32 AM


Document Has Been Signed on 07/01/2024 11:43 AM - 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:LAS PALMAS HOME CAREFACILITY NUMBER:
306002065
ADMINISTRATOR:MARTHA SERNAFACILITY TYPE:
740
ADDRESS:116 W. LAS PALMAS DR.TELEPHONE:
(714) 773-0055
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 4DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:16 AM
MET WITH:Martha SernaTIME COMPLETED:
11:50 AM
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) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Martha Serna and explained the reason for the visit. LPA and the Administrator toured the facility. LPA observed the PUB 475 poster was posted in the entry way of the facility but was 8 1/2 by 11 inches. The facility is a single story house with 6 bedrooms, living room, dining room, kitchen, laundry room, 4 bathrooms and an attached 3 car garage. The garage is used for storage and kept locked. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the knives and cleaning supplies are kept in the kitchen inaccessible to residents secured under the sink and in a kitchen drawer. LPA observed a seating area in the living room for residents to have visitors or to watch TV. The fireplace in the living is screened. LPA and the administrator toured the resident bedrooms. There are 6 bedrooms, 1 is for staff the rest are for residents. 1 of the resident bedrooms (the master bedrooms) can be shared. LPA observed all residents rooms had the required furnishings and bed linens. LPA observed all 4 bathrooms are clean and operational. How water measured between 105.0 degrees Fahrenheit and 108.1 degrees Fahrenheit. The smoke detectors/carbon monoxide detector tested operational. LPA and the Administrator toured the backyard. LPA observed there is a pool in the backyard. The patio area is fenced which makes the pool inaccessible to anyone in the house. The patio has a shaded seated area for the resident. The exit gate is operational. No obstacles or hazards observed in the backyard. The garage is kept locked and used for storage. LPA reviewed 4 resident records, no discrepancies observed. LPA reviewed 4 resident medications, no discrepancies observed. LPA reviewed 2 staff files. LPA observed staff 1 did not have the required 20 hours of annual training. Both staff members had current CPR training. LPA observed the first aid kit not have a current edition first aid manual. Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Executive Director and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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 4


Document Has Been Signed on 07/01/2024 11:43 AM - 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: LAS PALMAS HOME CARE
FACILITY NUMBER: 306002065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff members, staff 1 did not have 20 hours of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee agrees to have staff member 1 complete the 20 hours of annual training and to submit proof to the LPA by the POC 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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4