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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002430
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:48:59 PM


Document Has Been Signed on 09/20/2022 01:48 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:FAMILY CARE - BUCKBOARD HOMEFACILITY NUMBER:
306002430
ADMINISTRATOR:RUSSELL VENANZIFACILITY TYPE:
740
ADDRESS:25042 BUCKBOARD LANETELEPHONE:
(949) 362-2967
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 5DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Ginger Venanzi, Gloria SabidoTIME COMPLETED:
02:05 PM
NARRATIVE
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On 09/20/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Family Care- Buckboard Home. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 9:44am, LPA Cho was greeted and allowed entry by Care Staff Gloria Sabido and completed the Coronavirus 2019 (COVID-19) screening procedure. Care staff Sabido contacted and informed Licensee Russel Venanzi of LPA's arrival. Care Staff Rubie Mae Saban and Staff 2 (S2) were also present at the facility today. Staff 1 (S1) was fingerprint cleared but was not associated to this facility. Staff 2 (S2) did not have a Criminal Background Clearance. Per interviews of Staff 3 (S3) and Licensee, S2 was visiting and assisting with chores. S2 left the facility around 10:00am. As of today, there are no active COVID-19 cases. Per Care Staff Sabido, facility does not screen and document temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs throughout the facility. The facility did not have the Complaint Poster (PUB475). The facility is licensed for six non-ambulatory residents and has a hospice waiver for two. There are currently five residents living in the facility of which one is receiving hospice care.

At 10:05am, LPA Cho conducted a tour of the physical plant with Care Staff Sabido. The single-story home consists of five resident bedrooms and two resident bathrooms. There is one staff bedroom. The facility also has a living room, dining area, office area, kitchen, laundry room, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in both bathrooms. LPA tested the hot water temperature in the resident bathrooms and the temperature measured at 116.0 degrees Fahrenheit in the Bathroom #1 and 116.7 degrees Fahrenheit in Bathroom #2.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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 09/20/2022 01:48 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: FAMILY CARE - BUCKBOARD HOME
FACILITY NUMBER: 306002430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, 4 bottles of cleaning supplies were unsecured on the floor of the laundry room which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee immediately removed and locked the cleaning solutions and agrees to submit a proof of training of staff to LPA via email by POC due date.
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, one out of three individuals were not fingerprint cleared prior to volunteering which poses an immediate Health, Safety, or Personal Rights risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee agrees to fingerprint clear all individuals prior to working, residing, or voluteering and submit a fingerprint clearance of S2 by POC due date to LPA via email.

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) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FAMILY CARE - BUCKBOARD HOME
FACILITY NUMBER: 306002430
VISIT DATE: 09/20/2022
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LPA Cho inspected the kitchen along with Care Staff Sabido. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was charged. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications and sharps were locked and inaccessible to the residents. Three bottles of cleaning solutions and one disinfectant were observed on the floor in the laundry room and were immediately removed by Licensee Ginger.

LPA Cho toured the outside grounds with Care Staff Sabido. There was a shed that stored furniture. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gate was self-closing and self-latching. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components except a first aid manual, and the facility had additional supply of PPEs.



At 10:55am, LPA Cho spoke to Licensee Russell Venanzi via a telephone call, and Licensee Ginger Venanzi arrived shortly at 10:59am. LPA consulted the following with Licensee Ginger: to take temperatures of all visitors prior to entry, to ensure cleaning supplies and disinfectants are secured, to ensure individuals are associated and fingerprint cleared prior to volunteering in a licensed facility, to obtain the Complaint Poster (PUB475) and the first aid manual. LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov. Licensee Ginger Venanzi left the facility around 12:50pm and understands the above-mentioned, and authorized Care Staff Gloria Sabido to sign the report.

Based on the observations made during today's visit, deficiencies are cited in this review as per Title 22 Division 6 of the California Code of Regulations, therefore an immediate civil penalty is assessed. Advisory Notes (LIC9102s) were issued during the visit. The exit interview was conducted with Care Staff Gloria Sabido, and a copy of this report (LIC809, LIC809-C, LIC809-D, LIC421, LIC9102s, and the appeal rights) were provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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