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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002916
Report Date: 02/03/2025
Date Signed: 02/03/2025 04:35:59 PM

Document Has Been Signed on 02/03/2025 04:35 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:ARC FACILITY AT CAMINO 2FACILITY NUMBER:
306002916
ADMINISTRATOR/
DIRECTOR:		MICHAEL ADAMSFACILITY TYPE:
740
ADDRESS:2209 CAMINO DEL SOLTELEPHONE:
(714) 870-5830
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 4DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator Michael AdamsTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by Administrator (AD) Michael Adams after explaining the purpose for the visit. LPA observed that Michael Adam's Administrator Certificate expired on July 24, 2024. However, LPA verified and confirmed that AD submitted his renewal application to the Administrator Certification Bureau (ACB) on 07/24/2024.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for two. The facility is a single-story home with three resident bedrooms, two of which are shared, one staff room, two resident bathrooms, one of which is shared, a living room, a dining room, a kitchen, and an attached three car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed four residents in care, none of which are receiving hospice care, and two staff present. LPA observed residents relaxing in dining room and in the living room. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected all three resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA observed that staff room is kept locked and inaccessible to residents in care. LPA inspected the two resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 110.3 and 114.6 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916
VISIT DATE: 02/03/2025
NARRATIVE
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LPA observed kitchen appliances to be clean and operational. The four burner gas stove lights unassisted. LPA observed kitchen knives are stored in a locked kitchen cabinet. A fire extinguisher is located in the dining room and it was observed to be charged and up to date on service. LPA tested the individual smoke detectors and carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on January 25, 2025. The centrally stored medication is kept in a locked kitchen cabinet. LPA observed a First Aid kit stored in the closet in the resident hallway. The First Aid kit was observed to have all the required components. The door leading to the attached three car garage is kept locked and inaccessible to resident in care. LPA observed the three car garage is used for storage and for laundry. LPA observed chemical and toxins to be stored in the garage. LPA observed the facility has a three day emergency water supply stored in the garage. LPA observed the facility does not have a sufficient three day emergency food supply on hand.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side of the facility is self-latching and can be opened in an evacuation. LPA observed a pool located in the backyard which is adequately fenced and kept locked for resident safety.

LPA reviewed all four resident files. LPA observed that the Reappraisals for Resident #1 and Resident #2 were outdated. LPA reviewed four residents’ medication and medication records. LPA observed that the facility did not have a record of centrally stored prescription medications for Resident #2. LPA reviewed two staff files. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Michael Adams. A copy of the report was explained and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/03/2025 04:35 PM - It Cannot Be Edited


Created By: Brandon Lopez On 02/03/2025 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
The licensee shall be responsible for assuring that a record of centrally stored prescription mediciations for each resident is maintained for at least one year and includes:

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 which poses an immediate health, safety or personal rights risk to persons in care. During resident medication review, LPA observed that the facility did not have a record of centrally stored prescription medication for Resident #2 (R2). The facility did not have a record R2's Lorazepam and Ondansetron.
POC Due Date: 02/04/2025
Plan of Correction
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AD documented the prescription medications for R2 during the visit. POC cleared at time of visit.
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 Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/03/2025 04:35 PM - It Cannot Be Edited


Created By: Brandon Lopez On 02/03/2025 at 04:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the Reappraisals for Resident #1 (R1) and Resident #2 (R2) were outdated. LPA observed that the most recent Reappraisal on file for R1 was completed on 04/30/23. LPA observed that the most recent Reappraisal on file for R2 was completed on 01/09/23.
POC Due Date: 02/17/2025
Plan of Correction
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AD agreed to complete a new Reappraisal for R1 and R2. AD agreed to submit proof of completion to LPA via email or fax by POC date.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 which poses/posed a potential health, safety or personal rights risk to persons in care. During a tour of the physical plant, LPA observed that the facility does not have a sufficient three day emergency food supply on hand.
POC Due Date: 02/10/2025
Plan of Correction
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AD agreed to purchase a three day emergency food supply. AD agreed to submit proof of purchase by a receipt to LPA via email or fax by POC date.
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
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
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