306002536-10-4-2021-22-AS-RQUZ-C7H73Z-20211004211906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002536
Report Date: 09/29/2021
Date Signed: 10/04/2021 09:19:53 PM

COMPREHENSIVE INSPECTION

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:	CARE OF HEART FOR ELDERLY IN ORANGE		FACILITY NUMBER:	306002536
ADMINISTRATOR:	MYRNA ADRIANO		FACILITY TYPE:	740
ADDRESS:	3342 E. MAPLE AVENUE		TELEPHONE:	(714) 633-4607
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 5	DATE:	09/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Pilar Biaoco, Caregiver and Myrna Adriano, Administrator		TIME COMPLETED:	02:16 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by caregiver Pilar Biaco and explained the nature of the visit. Administrator Myrna Adriano arrived to facility at 12:56pm. This facility is licensed to provide services to 5 Non-Ambulatory Residents with one (1) bedridden , and has a hospice waiver for four (4) residents. Administrator (AD)Myrna Adriano has an Administrator Certificate with expiration date of 3/3/2023.

On or about 12:27pm LPA Quiroz along with Caregiver Pilar Biaco toured the inside and outside of facility except garage area. Caregiver indicated "Only the Administrator has a key for garage." Two staff working at facility were observed to be wearing face masks upon arrival to facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz interacted with four of five residents in care. One of five residents in care was sleeping. Five of five residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. LPA Quiroz observed a check in station in the main entry of the facility. However, upon LPA Quiroz entering facility, staff did not screen LPA Quiroz. LPA Quiroz requested to be screened and have temperature checked and recorded prior to entering facility . L/AD Adriano indicated "We were not recording visitors temperatures, but we will now." Facility is taking temperatures daily of residents and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has minimal emergency food, water supply and PPE supplies readily available. L/AD Adriano indicated "I will go out and purchase more." Between 1:00pm-1:26pm, LPA Quiroz toured the outside of the facility along with L/AD Adriano. Facility has completed the LIC 808 Mitigation plan, which was approved by LPA Micah Martinez on 3/10/2021.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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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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: CARE OF HEART FOR ELDERLY IN ORANGE	FACILITY NUMBER: 306002536
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2021 Section Cited	1 2 3 4 5 6 7	Maintenance & Operation 87303(a):The facility shall be clean, safe, sanitary and in good repair at all times...for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Between 1:00pm-1:18pm, LPA Quiroz observed clutter in garage area with no...CONT
	8 9 10 11 12 13 14	accessibility to enter garage from door near kitchen area and no accessibility to walk into the garage. LPA Quiroz observed a white vehicle parked with expired plates. L/AD Adriano indicated "It's non operational." At 1:20pm, LPA Quiroz observed clutter in backyard area with no availability for residents or visitors to sit and enjoy...	8 9 10 11 12 13 14	...outdoor area and eight trash size bags recycle in backyard.At 1:26pm, LPA Quiroz observed machinery tools on bench in outdoor back yard area.
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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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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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: CARE OF HEART FOR ELDERLY IN ORANGE	FACILITY NUMBER: 306002536
	VISIT DATE: 09/29/2021

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During today's inspection visit, LPA Quiroz reviewed five of five resident records.

Based on the observation made during today’s visit, the following deficiency (listed on the LIC809-D attached) was observed and are being cited per Title 22, Division 6, of the California Code of Regulations.

This report was reviewed with Licensee/Administrator Myrna Adriano, deficienciynd appeal rights were discussed with Licensee/Administrator Adriano, and a copy of this report, LIC 809-D, Appeal rights and LIC 9102 Technical Assistance was provided to Licensee/Administrator Adriano at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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