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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002482
Report Date: 05/10/2024
Date Signed: 05/10/2024 04:46:17 PM


Document Has Been Signed on 05/10/2024 04:46 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 ASC, 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:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Carol Wilson - AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Faith La arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted and granted entry into facility by Karen Moralde and John Moralde, Caregivers. Facility Administrator Carol Wilson joined the inspection after the tour.

The facility is a one-story home with six client bedrooms, one staff room, three bathrooms, kitchen, dining room, living room, TV room, backyard and attached 2-car garage. LPAs noted there are two vacancies at the facility. All four residing residents were present. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for residents in the hallway closet. Restrooms are stocked with soap and paper towels. LPAs measured water all three bathrooms. LPAs measured hot water to be 109.8, 114.2 and 110.5 degrees Fahrenheit in the three bathrooms. LPAs noted Fire Extinguisher was last serviced on 04/22/2024.

LPAs observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a kitchen cabinet. The backyard has a shaded sitting/lounging area. Exit gate is unlocked. LPAs observed exit gate to be unobstructed. LPAs reviewed two of the four resident files and three staff files. LPAs also reviewed medication for two out of four clients. LPAs interviewed two residents and two staff. LPAs issued Technical Assistances (TA) to advise the facility to maintain a plan of operation including a dementia care plan and bedridden care plan.

Based on record review, LPAs determined that only one disaster drill was conducted and documented at the facility in the last year.

Two deficiencies are being issued based on today's inspection. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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 5


Document Has Been Signed on 05/10/2024 04:46 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CAREWELL MANOR

FACILITY NUMBER: 306002482

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to the appearance of dirt and other indicators in the kitchen and bathroom in the shared room. This posesd a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Facility staff cleaned the medicine cabinet in the shared room bathroom during the inspection. AD stated they will hire exterminators to come out to the facility and spray the bathroom, kitchen and any other areas where bugs have been seen. AD stated they will email LPA to notify them of the scheduled date of service. AD stated they will email LPA upon completion of the service.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in due to the facility maintaining record of only one disaster drill in at least the last year. This poses a potential safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator stated they will schedule their next quarterly drill for July 2024 and email LPA to notify them of the scheduled drill by the assigned POC due date of 5/17/24.
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 LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5