306002960-5-25-2023-22-AS-SHAD-CS6SVP-20230525141305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002960
Report Date: 05/25/2023
Date Signed: 05/25/2023 02:13:10 PM

Document Has Been Signed on 05/25/2023 02:13 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:	STANFORD HOMES-ANAHEIM		FACILITY NUMBER:	306002960
ADMINISTRATOR:	ALFREDO A. CHU		FACILITY TYPE:	735
ADDRESS:	328 N. VINE STREET		TELEPHONE:	(714) 808-1600
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY: 15		CENSUS: 12	DATE:	05/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Albert Chu		TIME COMPLETED:	02:25 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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Albert Chu and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 9:45AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure. This is a one-story residential building. Facility is a 9-bedroom, 4-bathroom, one-story residential building with 2 attached garages that are being used for storage. There is a yard with a patio cover for the clients. LPA observed 1 staff, not including AD, and 11 clients present at the facility. Client Bedrooms. The 8 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms. The 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 106.7 and 108.6 F degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. Linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the garage and under the kitchen sink. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed licensing fees with AD. At about 10:30AM, LPA reviewed 5 client files and 5 staff files, interviewed 5 clients and 1 out of 1 staff, inspected medications for 5 clients, and inspected client money and ledger for 5 clients

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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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Document Has Been Signed on 05/25/2023 02:13 PM - It Cannot Be Edited

Created By: Sean Haddad On 05/25/2023 at 01:52 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: STANFORD HOMES-ANAHEIM	FACILITY NUMBER: 306002960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records, the licensee did not ensure 1 out of 5 clients recieved 1 pill of their medication in the last month as a loose pill was found with the bubble packs, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	Licensee stated they will notify the client's doctor, properly dispose of the medication, and retrain staff on medication protocols and submit proof to LPA by POC due date.

Type A

Section Cited

CCR

80026(h)(1)

80026 Safeguards for Cash Resources… (h) Each licensee shall maintain accurate records of accounts of cash resources …: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting …. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and documents, the licensee did not ensure 3 out of 5 client cash resources matched their ledgers, which poses an immediate personal rights risk to clients in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	During the inspection, the licensee added money to the client's missing cash resoures and LPA confirmed. Licensee stated they will conduct an audit to determine the cause of the extra money and send a report to LPA by POC due date with their findings.

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: STANFORD HOMES-ANAHEIM	FACILITY NUMBER: 306002960
	VISIT DATE: 05/25/2023

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During the inspection, LPA and AD observed the following: the cash resources and ledger for Client #1 (C1) did not match as the cash resources were short 20 dollars and also did not match for Client #2 (C2) and Client #3 (C3) as the cash resources contained an extra 30 dollars for each client; C3’s medication bubble packs for the last month contained 1 loose pill of Clozapine which C3 did not receive. During the inspection, AD added 20 dollars to C1’s cash resources and LPA confirmed. LPA provided technical assistance regarding Infection Control Plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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