306002482-11-26-2024-22-AS-DLMN-DBE4GJ-20241126180536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002482
Report Date: 11/26/2024
Date Signed: 11/26/2024 06:07:22 PM

Document Has Been Signed on 11/26/2024 06:07 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 MANOR		FACILITY NUMBER:	306002482
ADMINISTRATOR/ DIRECTOR:	CAROL WILSON		FACILITY TYPE:	740
ADDRESS:	3330 W. STONYBROOK DRIVE		TELEPHONE:	(714) 827-8520
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Carol Wilson - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 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	Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Nancy Guillen arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Carol Wilson, Administrator and explained the purpose of the inspection. The facility is one-story building with 5 resident rooms, 3 bathrooms, kitchen, dining room, living room, den, staff room, backyard and 2-car garage. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed nails on the backyard table, an inoperable shower, oven is missing an igniter knob, light in the refrigerator in inoperable, broken drawer in the kitchen and two sinks not draining. A deficiency is being issued. LPAs observed 3 trash cans without lids, a deficiency is being issued. LPAs observed bleach in two accessible areas. A deficiency is being issued. Hot water measured between 105 and 120 degrees F. LPAs observed facility has emergency food and water supply. LPAs reviewed facility files. Base on file review, LPAs determined the facility does not have a dementia care plan. A deficiency is being issued. LPAs reviewed five staff files and six resident files. LPAs conducted interviews with five residents and two staff. LPAs reviewed medication. Based on medication review, LPAs determined the facility does not have a current record of dosages for prescribed medication or prescribed PRNs. Two deficiencies are being issued. LPAs also observed multiple residents' medication in pill containers up to one week in advance. One deficiency is being issued. Based on today's inspection, seven deficiencies are being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.

Armando J Lucero	TELEPHONE: (949) 430-1222
Dwayne L Mason	TELEPHONE: () -
	DATE: 11/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

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 11/26/2024 06:07 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to the presence of accessible bleach in two locations in the facility. This poses an immediate safety or risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Administrator stated they will move all chemicals to a location inaccessible to residents by the assigned plan of corrections due date.

Section Cited

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on PRN medication review and PRN medication record review, the licensee did not comply with the section cited above due to the absence of a record of PRN doses administered to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Administrator stated they will conduct an in-service training regarding PRN Medication Administration and Documentation by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics covered. AD stated they will email LPA all documentation for this training by the assigned Plan of Correction due date of November 27.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (949) 430-1222
Dwayne L Mason	TELEPHONE: () -
	DATE: 11/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/26/2024 06:07 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Plan of Operation

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above due to the absence of a dementia care plan. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator stated they will create and maintain in the facility a dementia care plan. Administrator stated they will email the completed plan to LPA by the assigned plan of corrections due date.

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above due to the presence of nails on the backyard table, an inoperable shower, a missing igniter knob on the oven, an inoperable light in the refrigerator, a broken drawer in the kitchen and two bathroom sinks not draining. This poses a potential safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator stated they will remove the nails on the backyard table, replace the missing igniter knob on the oven, repair the shower, refrigerator light, kitchen drawer and bathroom sinks by the assigne plan of corrections due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (949) 430-1222
Dwayne L Mason	TELEPHONE: () -
	DATE: 11/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/26/2024 06:07 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to the absence of lids on three trash cans. This poses a potential health risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator stated they will acquire tight-fitting lids for all trash can in the facility and place them on all trash cans by the assigned plan of corrections due date.

Section Cited

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication and medication record review, the licensee did not comply with the section cited above due to the absence of a record of doses administered to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator stated they will conduct an in-service training regarding Medication Administration and Documentation by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics covered. AD stated they will also maintain an updated MAR for medication and PRN as well as email LPA all documentation for this training by the assigned POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (949) 430-1222
Dwayne L Mason	TELEPHONE: () -
	DATE: 11/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/26/2024 06:07 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above in due to multiple residents' medication being transferred between containers which poses a potential health or safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator stated they will conduct an in-service training regarding Medication Storage by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics covered. AD stated they ensure medication is stored in the originally receied containers and will email LPA all documentation for this training by the assigned Plan of Correction due date of December 10, 2024.

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.

Armando J Lucero	TELEPHONE: (949) 430-1222
Dwayne L Mason	TELEPHONE: () -
	DATE: 11/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

LIC809 (FAS) - (06/04)

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