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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002286
Report Date: 03/29/2023
Date Signed: 03/29/2023 04:40:57 PM

Document Has Been Signed on 03/29/2023 04:40 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:R & R CARE, INC.FACILITY NUMBER:
306002286
ADMINISTRATOR:ROMAN MATAGAFACILITY TYPE:
740
ADDRESS:14952 BURNHAM CIRCLETELEPHONE:
(949) 651-1830
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 6CENSUS: 6DATE:
03/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Roman Mataga, AdministratorTIME COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting a deficiency observed during the initial investigation visit for complaint reference 22-AS-20230327134042. LPA was greeted and granted entry by caregiving staff who notified administrator of the visit via telephone. Administrator arrived later to assist with the visit.

During the visit, LPA requested, obtained and reviewed resident records for all six residents present. Records kept at the facility were found to be incomplete in multiple instances. There is no medical assessment on file for resident R1. Resident was admitted from a Skilled Nursing Facility with a hospice service already providing care but the physician report was requested but never obtained.

Signed admission agreements are missing from the records maintained at the facility for resident R2 and R3.

Individual Needs and Services Plan and Resident Assessments are also absent from the records maintained at the facility for residents R2, R4 and R5.

A type B citation is being issued for this deficiency.

An exit interview was provided and a copy of this report along with appeal rights was provided and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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 03/29/2023 04:40 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 03/29/2023 at 04:17 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: R & R CARE, INC.
FACILITY NUMBER: 306002286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2023
Section Cited
CCR
87506(a)

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The California Code of Regulations Section 87506 on Resident Records states that: "(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility (...) readily available (...) to licensing agency staff. This requirement is not met as evidenced by:
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Licensee will provide updated documents for the missing physician report, needs assessments and admission agreements before the Plan of Corrections due date.
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Multiple instances of incomplete files missing documents such as the medical assessment, admission agreement or needs assessment have been found during a review of records at the facility. This poses a potential risk to the health, safety and personal rights of residents in care.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


LIC809 (FAS) - (06/04)
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