306002966-8-16-2024-22-AS-JCHO-D87PEV-20240816111547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002966
Report Date: 08/16/2024
Date Signed: 08/16/2024 11:16:02 AM

Document Has Been Signed on 08/16/2024 11:16 AM - 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:	SWEET HOME CARE		FACILITY NUMBER:	306002966
ADMINISTRATOR:	NICOLETA BLAGA		FACILITY TYPE:	740
ADDRESS:	14681 WILSON STREET		TELEPHONE:	(714) 901-0705
CITY:	MIDWAY CITY	STATE: CA	ZIP CODE:	92655
CAPACITY:	6	CENSUS: 5	DATE:	08/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Nuta Miller- Caregivers		TIME COMPLETED:	11:30 AM

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	Licensing Program Analysts (LPAs) Jessica Cho and William Vanegas arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPAs were greeted and granted entry by Caregiver Ana Bistroi. Licensee/Administrator Nicoleta Blaga was unavailable during the inspection however consented by telephone for a staff to sign the report on her behalf. The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory and maintains a hospice waiver for three (3). There are five residents in care during today's visit with two caregivers on duty. LPAs observed the facility to be clean and sanitary. There are six resident bedrooms and four resident bathrooms. One bedroom was not occupied by a resident. All common areas were inspected including the attached two car garage and laundry room. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 115.5, 109.5, 109.5, and 108.8 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPAs observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available. LPAs toured the exterior portion of the facility. LPAs observed the outdoor passageway free of obstruction. The exit gates were self-closing and self-latching. LPAs observed sufficient seating and shading. Facility maintains a fire extinguisher which was purchased on June 5, 2024. The auditory devices and dual-functioning smoke/carbon monoxide detectors were tested and operational. LPAs observed the emergency disaster supplies including food/water in the medication closet. Emergency evacuation drills are being conducted quarterly. The first aid kit contains all necessary elements.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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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Document Has Been Signed on 08/16/2024 11:16 AM - 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: SWEET HOME CARE	FACILITY NUMBER: 306002966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, interview, and record review, facility did not maintain bed rail orders for two out five residents which poses a potential health/safety risk to persons in care.
	POC Due Date: 08/23/2024
	Plan of Correction
1 2 3 4	Please obtain bed orders and submit to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SWEET HOME CARE	FACILITY NUMBER: 306002966
	VISIT DATE: 08/16/2024

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LPAs observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the family room in the back of the house. The Administrator's Certificate for Nicoleta Blaga expires on February 9, 2025.

LPAs conducted an audit of five residents' files and two personnel files. No discrepancies were noted. Staff and resident interviews were conducted. Medications were audited. No discrepancies noted.

Admin was advised on the following: to post the Complaint Poster in the main entryway and to obtain doctors' orders for the bed rails for two out of five residents.

Based on the observations made during today's visit, a deficiency is being cited, and a Technical Violation is being issued.

An exit interview was conducted with Caregiver Nuta Miller, and a copy of this report and the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC809 (FAS) - (06/04)

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