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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002885
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:52:50 PM


Document Has Been Signed on 06/27/2022 03:52 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
CCLD Regional Office, 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: 5DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gina Severino - Caregiver, Arlene Fajardo- Administrator TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by Caregiver Gina Servino and explained the reason for the visit. Administrator Arlene Fajardo arrived at 2:10 PM

At 2:10 PM, LPA toured facility with Administrator Arlene Fajardo. Facility has 5 residents present during today’s visit. Facility is a 7 bedroom, 3 bathroom, two story home with an attached garage. LPA observed a screening and sanitizing station at entrance of the facility. LPA observed residents relaxing in the facility or in their respective rooms. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for resident medication and files. LPA toured the outside grounds and observed outside visitation areas. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA reviewed all residents’ files and all contained required documentation including updated emergency information. All staff and residents are fully vaccinated for Covid 19.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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 3


Document Has Been Signed on 06/27/2022 03:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CASTLEGATE MANOR
FACILITY NUMBER: 306002885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632
in order accept or retain terminally ill residents... receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver... the licensee shall submit a written request for a waiver.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Licensee failed to obtain a hospice waiver increase for residents in care. Facility has a hospice waiver for two residents but currently has 4 residents on hospice. This poses a potential health and safety risk to residents in care.
POC Due Date: 07/04/2022
Plan of Correction
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Licensee to request a hospice waiver increase from 2 to 4 to LPA by 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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/27/2022 03:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CASTLEGATE MANOR
FACILITY NUMBER: 306002885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed adult family member living in facility without background clearance which poses an immediate health and safety risks to persons in care.
POC Due Date: 06/28/2022
Plan of Correction
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Licensee to obtain background clearance and associate adult family member prior to re-entry to facility by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3