306002455-5-4-2023-22-AS-CGUZ-CRHU3C-20230504151320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002455
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:13:28 PM

Document Has Been Signed on 05/04/2023 03:13 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	INDEPENDENT OPTIONS INC/ANACAPA HOUSE		FACILITY NUMBER:	306002455
ADMINISTRATOR:	BUTCH MALLILLIN		FACILITY TYPE:	735
ADDRESS:	2538 ANACAPA DRIVE #105		TELEPHONE:	(714) 556-2591
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 4		CENSUS: 4	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Mayra Hernandez Leilani Whitfield		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Staff Mayra Hernandez. LPAs discussed the purpose of the inspection. Administrator (AD) Leilani Whitfield arrived at 10:30am.

During the inspection LPAs and Staff Hernandez conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and observed the following:

This is a one-story apartment with four client bedrooms, four bathrooms and no staff bedroom. All client bedrooms had the required furnishings. LPAs observed all client beds had linens and blankets. LPAs observed all windows were screened. There are three outdoor patios and a shaded sitting area. LPAs observed one staff and four clients present. Bathroom faucets and toilets were operational. Water temperature tested at 105 F degrees. Three out of four gas stove burners tested inoperable, and bathrooms were observed to have cobwebs on shower curtain rods; a Deficiency was issued on today’s date. LPAs observed facility sketch and means of exiting posted at the entrance of the facility. Emergency disaster plan was also observed in facility’s Fire/Disaster binder. Food menu was posted and visible. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Kitchen refrigerator tested operable. Sharps were observed locked under the sink away from chemicals. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication was observed to be locked. The first aid kit has all the required elements. LPAs reviewed four client files and four staff files. LPAs interviewed four clients and one staff.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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 05/04/2023 03:13 PM - It Cannot Be Edited

Created By: Claudia Gutierrez On 05/04/2023 at 02:11 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: INDEPENDENT OPTIONS INC/ANACAPA HOUSE	FACILITY NUMBER: 306002455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation licensee did not comply with the section cited above as three out of four burners on gas stove tested inoperable, and one out of four bathrooms was observed to have cobwebs on shower curtain rods, which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/03/2023
	Plan of Correction
1 2 3 4	AD stated they would contact Harbor Village to put in a work order to replace or repair the stove. AD also stated they will implement more detailed cleaning requirements in the staff daily duties. AD will provide LPA with a copy of purchase receipt or work order for stove via email by POC date. During visit AD provided LPA with updated sheet of staff daily duties.

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Claudia Gutierrez

LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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