306002536-9-13-2024-22-AS-ARJR-D93VAE-20240913161550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002536
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:15:55 PM

Document Has Been Signed on 09/13/2024 04:15 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:	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: 2	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:28 PM
MET WITH:	Carolyn Nuestro-Caregiver, Myrna Adriano-Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Carolyn Nuestro. Administrator (AD) Myrna Adriano arrived shortly after.

For today’s visit, LPA observed a total of two residents in care and one staff member on duty.

LPA observed the Administrator's Certificate for facility AD Myrna Adriano which expires on March 03, 2025.

LPA Ramirez toured the interior and exterior portions of the facility with AD Adriano. The facility is a single level structure and is licensed for five non-ambulatory residents, of which four may be on hospice and one bedridden. There are a total of four bedrooms, of which three are resident bedrooms, and one private bedroom for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of three restroom. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 112.8-114.2 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged and located by the laundry room.

CONTINUED ON LIC809-C..

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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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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: CARE OF HEART FOR ELDERLY IN ORANGE	FACILITY NUMBER: 306002536
	VISIT DATE: 09/13/2024

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LPA observed the emergency disaster and evacuation plan which is located by the residents' bedroom hallway. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which both is self-closing and self-latching. LPA observed a pool which fenced by a 5 feet height metal fence. LPA observed that the pool had no water.

During today's visit LPA observed residents watching television in their bedroom.

LPA reviewed two resident files and two staff files. LPA observed that one of two resident files did not have an Admission Agreement. LPA interviewed residents and staff present.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Adriano.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 04:15 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: CARE OF HEART FOR ELDERLY IN ORANGE	FACILITY NUMBER: 306002536
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. 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 in which poses a potential health, safety or personal rights risk to persons in care. LPA observed that one of two resident files did not have an Admission Agreement.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee to email LPA a signed and dated Admission Agreement by POC due date.

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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