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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002550
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:04:49 PM


Document Has Been Signed on 07/22/2024 03:04 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:CHERI MANORFACILITY NUMBER:
306002550
ADMINISTRATOR:MARIA GOFACILITY TYPE:
740
ADDRESS:1160 CHERI DRIVETELEPHONE:
(562) 690-5700
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caregiver, Marissa AcerboTIME COMPLETED:
03:15 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 7/22/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Caregiver, Marissa Acerbo who was informed of the purpose of the visit. Licensee, Maria Go was contacted over-the-phone and informed of the purpose of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for three (3). During today's visit, there was two (2) staff and four (4) residents present.

LPA toured the facility with Caregiver Acerbo. During the tour, LPA observed the facility is made up of a two-story home with four (4) resident bedrooms, three (3) bathrooms, two (2) staff rooms, a kitchen, dining room, office and attached garage. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating available for the residents in care. No bodies of water were observed on the premises. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilet and in the shower along with non-skid mats. LPA toured the kitchen and observed food is stored in a safe and healthful manner. The facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Caregiver Acerbo tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility, serviced on 6/13/2024. LPA reviewed random staff and resident files. Resident files reviewed had signed admission agreements and updated physician reports. Staff present have a criminal record clearance and valid first aid/CPR certification. Medications are secured in a locked cabinet in the office. LPA reviewed the physical medications for two (2) residents along with their Medication Administration Record. During review of the MAR, LPA discovered facility staff initialed the column for 7/23/2024, documenting as if they administered medication for tomorrow. Caregiver Acerbo showed LPA the facility transfers the residents' medications into a weekly pill organizer, only labeled with each of the residents' names. The facility will be cited pursuant to California Code of Regulations, Title 22.

An exit interview was conducted where this report was reviewed and provided to Caregiver Acerbo along with LIC 809-D and Appeal Rights.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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 07/22/2024 03:04 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: CHERI MANOR
FACILITY NUMBER: 306002550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
(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 observation and interview, the licensee did not comply with the section cited above by transferring four (4) residents' medication into a weekly pill organizer that is only labeled with each of the resident's name and signing the MAR a day in advance. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
1
2
3
4
Licensee reported they will conduct a staff training regarding medication management and proper documentation, and submit Proof of Correction (POC) to LPA by close of business on 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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2