Community Care Licensing

Document Has Been Signed on 11/04/2024 01:45 PM - It Cannot Be Edited

FACILITY NAME:	ARC FACILITY AT CAMINO 2		FACILITY NUMBER:	306002916
ADMINISTRATOR/ DIRECTOR:	MICHAEL ADAMS		FACILITY TYPE:	740
ADDRESS:	2209 CAMINO DEL SOL		TELEPHONE:	(714) 870-5830
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY: 6		CENSUS: 5	DATE:	11/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Michael Adams		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

SUPERVISORS NAME: Lourdes Montoya LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024

Link to Parent Document Below:

FACILITY NAME: ARC FACILITY AT CAMINO 2	FACILITY NUMBER: 306002916
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2024

Type A

Section Cited

CCR

87303

(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that he Licensee failed to keep the facility clean and in good repair at all times. LPA observed a leak under kitchen sink, kitchen cabinets needing repair, medication cabinet locks needs to be replaced, refrigerator needs deep cleaning, dining area needs to be cleaned and organized, common areas need deep cleaning and electric wires are a tripping hazard, hallway bathroom has a leak under the sink, both bathrooms need deep cleaning, garage needs to be organized and decluttered and walkway on side of garage has items blocking walkway going out to exit gate. Also, window screens need to be repaired/replaced. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee is to ensure the facility is clean, safe, sanitary and in good repair at all times. Licensee to submit a plan areas of concern above and on section cited and submit to LPA by 11/5/2024. LPA to conduct a visit in near future.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Lourdes Montoya LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024

Link to Parent Document Below:

FACILITY NAME: ARC FACILITY AT CAMINO 2	FACILITY NUMBER: 306002916
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2024

Type A

Section Cited

CCR

87307

Personal Accommodations and Services - (e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds...swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering, or other means. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Licensee did not comply with the section cited above in that the Licensee did not ensure the swimming pool to be secured, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee to obtain and install a lock on the backyard pool and submit proof to LPA by POC due date.

Type A

Section Cited

CCR

87202

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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; Licensee stated Fire Extinguisher had not been serviced in a couple years; Licensee failed to ensure Fire Extinguisher was serviced annually, which poses an immediate health, and safety risk to the residents in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee to purchase or have Fire Extinguisher serviced and submit proof of POC by due date.

SUPERVISOR'S NAME: Lourdes Montoya LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024

Link to Parent Document Below:

FACILITY NAME: ARC FACILITY AT CAMINO 2	FACILITY NUMBER: 306002916
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2024

Type B

Section Cited

CCR

87555

General Food Service Requirements - (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 in that Licensee failed to ensure food on hand met the minimum of one week non-perishable and minimum of two days perishables. Food observed is not enough to feed 5 residents for 7 days. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee to ensure there is enough food on hand at all times, agrees to have perishable and non-perishable food items to meet the requirement. Proof of correction will be provided to CCL by the POC date of 11/5/2024

Type B

Section Cited

CCR

87156

Annual Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in that Licensee failed to pay the annual licensing fees which were due 02/20/2024; however; the Licensee has not paid the annual fees by the due date in the past 3 years, and for this reason, late fees have been accrued. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee to pay balance of $1,236.50 and provide LPA with proof of the full payment by POC due date of 11/5/2024..

SUPERVISOR'S NAME: Lourdes Montoya LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024

Link to Parent Document Below:

FACILITY NAME: ARC FACILITY AT CAMINO 2	FACILITY NUMBER: 306002916
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2024

Type B

Section Cited

CCR

87608

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in R1 had a full bed rail and is not receiving hospice services, R2 and R3 have 1/2 bed rails no written order from a physician were found in files. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Licensee to remove the bed rails and/or obtain physician orders for half-bed rails if there is a need and submit copy of orders to CCL by 11/15/2024

SUPERVISOR'S NAME: Lourdes Montoya LICENSING EVALUATOR NAME: Lydia Martinez LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024