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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002482
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:20:42 PM


Document Has Been Signed on 04/29/2024 12:20 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAREWELL MANORFACILITY NUMBER:
306002482
ADMINISTRATOR:CAROL WILSONFACILITY TYPE:
740
ADDRESS:3330 W. STONYBROOK DRIVETELEPHONE:
(714) 827-8520
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 4DATE:
04/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Carol Wilson, AdministratorTIME COMPLETED:
12:30 PM
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
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of issuing a citation for a deficiency. LPA was greeted and granted entry by facility administrator Carol Wilson after stating the purpose of the visit.

On April 22, 2024, an initial investigation visit was conducted for complaint reference #22-AS-20240416145901. LPA reviewed records maintained at the facility for resident R1. Per a physician report dated November 29, 2021, R1 is diagnosed with Parkinson's disease and was assessed to be bedridden. According to the facility's administrator, this is the most recent medical assessment on file with the exception of R1's hospice plan of care. Per the terms of its current license printed on April 20, 2018, the facility is licensed for 6 non-ambulatory residents and has a hospice waiver in place for a total capacity of 2 residents receiving hospice care. The facility is however not in possession of a fire clearance for a bedridden resident at this time.

A Type A citation for failure to meet the requirements of the California Code of Regulations Section 87606(c) was issued. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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 2


Document Has Been Signed on 04/29/2024 12:20 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CAREWELL MANOR
FACILITY NUMBER: 306002482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2024
Section Cited
CCR
87606(c)

1
2
3
4
5
6
7
Per CCR 87606(c) on the Care of Bedridden Residents: "To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance(...). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide increased two-person supervision to the resident as well as provide the Department with a written statement of its intent to obtain a bedridden fire clearance from the competent fire authority or seek alternative placement for R1.
8
9
10
11
12
13
14
Based on interview conducted, facility observation and a review of records, resident R1 has been assessed to be bedridden while the facility is not in possession of an adequate fire clearance. This constitutes an immediate risk to the health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2