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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002885
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:36:43 PM


Document Has Been Signed on 08/28/2024 02:36 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:CASTLEGATE MANORFACILITY NUMBER:
306002885
ADMINISTRATOR:ARLENE FAJARDOFACILITY TYPE:
740
ADDRESS:9422 CASTLEGATE DRIVETELEPHONE:
(714) 964-8390
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Arlene FajardoTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Arlene Fajardo and explained the reason for the visit. Arlene Fajardo's Administrator's Certificate expires on June 18, 2025. The facility is a two story home with 6 bedrooms (3 upstairs staff only, 3 downstairs residents only), kitchen, 2 bathrooms ( 1 upstairs and 1 downstairs) living room (with a screened fireplace), dining room, family room with a TV and a 2 car garage. LPA the Administrator and both staff present are background cleared and associated to the facility. LPA observed Resident 7, who resides at the facility, (R7) who is an adult relative of a staff member, not a staff member or volunteer, is not background cleared and not associated to the facility. LPA observed Resident 7 leave the facility. LPA and the Administrator toured the facility. LPA observed the fireplace in the living room is screened. LPA observed the See Something, Say Something Poster (PUB 475) is posted by the front door. The downstairs bathroom is for residents. LPA observed the bathroom is clean and operational. Hot water measured 123.2 degrees Fahrenheit. LPA observed the kitchen is clean and organized. Knives are kept locked in a kitchen drawer. LPA observed the 4 burner gas stove lights unassisted. LPA observed cleaning supplies are kept locked under the kitchen sink. Medications are kept locked in a kitchen cabinet. LPA toured the resident rooms. All resident rooms had the required furnishings and bed linens. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Smoke detectors/carbon monoxide detectors tested operational. LPA and the Administrator toured the backyard and garage. The garage is kept locked and used for storage of supplies and extra food. LPA observed a table with 4 chairs and an umbrella. There is a gated pool in the backyard. The gate is kept locked and inaccessible to residents. Both exit gates are operational. LPA reviewed staff files. LPA reviewed resident files and medications, LPA observed that 3 out of 4 residents did not have a current appraisal/needs and care plan (reappraisal).
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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: CASTLEGATE MANOR
FACILITY NUMBER: 306002885
VISIT DATE: 08/28/2024
NARRATIVE
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The Administrator reported they do conduct fire drills but there is no documentation to verify when the last fire drill was conducted. LPA inspected the first aid kit. The first aid kit did not have a first aid manual. LPA observed the facility has WiFi but does not have a internet device dedicated for resident use such as a laptop or tablet. The Administrator verified there is no laptop or tablet for residents. LPA interviewed staff and residents.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An immediate civil penalty was assessed today due to R7's lack of criminal record clearance or exemption. An exit interview was conducted with the facility Administrator and a copy of the report (LIC 809, LIC 809D) along with appeal rights was provided in addition to civil penalty assessment (LIC 421 BG) and civil penalty appeal rights.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 08/28/2024 02:36 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: CASTLEGATE MANOR
FACILITY NUMBER: 306002885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, R7 has no fingerprint clearance & is not associated with the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Licensee agrees to have R7 background cleared and associated to the facility prior to letting them reside in the facility. Licensee to forward proof to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 08/28/2024 02:36 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: CASTLEGATE MANOR
FACILITY NUMBER: 306002885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the hot water in the downstairs bathroom measure 123.2 degrees Fahrenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee agrees to adjust the hot water to be between 105.0 to 120.0 degrees Fahrenheit in the downstairs bathroom.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

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 3 out of 4 residents did not have a current appraisal/needs and care plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 08/28/2024 02:36 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: CASTLEGATE MANOR
FACILITY NUMBER: 306002885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, there is no record of the facility conducting any emergency or fire drills this year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee agrees to conduct an emergency drill in compliance with the above regulation and to document the emergency drill. Licensee to forward proof to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7