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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003423
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:49:54 AM

Document Has Been Signed on 06/12/2024 11:49 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:FLORES ADULT RESIDENTIAL HOMEFACILITY NUMBER:
306003423
ADMINISTRATOR/
DIRECTOR:		ZOILA FLORESFACILITY TYPE:
735
ADDRESS:2229 N. FOREST AVENUETELEPHONE:
(714) 542-3468
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 6CENSUS: 1DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:03 AM
MET WITH:Zoila FloresTIME VISIT/
INSPECTION COMPLETED:
12:04 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Zoila Flores and explained the reason for the visit. LPA and Administrator toured the facility. The facility is a two story home with 7 bedrooms, 4 bathrooms, 2 kitchens, living room, dining room and a TV room. Smoke detectors/carbon monoxide detectors tested operational. The last fire drill was conducted on March 13, 2024.. LPA observed the kitchen is clean and organized. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen. LPA observed medications and knives are kept locked in the closet. The garage is used to store extra supplies and food. There is an extra refrigerator and freezer in the garage. Cleaning supplies and chemicals are kept locked in the garage. LPA observed the fire extinguisher in the kitchen is fully charged. There a 3 bedrooms downstairs. 2 bedrooms are used for storage of old furniture and are not used by clients or staff. 1 bedroom downstairs is for staff. There are 4 bedrooms upstairs, 1 bedroom is for staff. There are 3 client rooms upstairs, 2 are private, 1 is shared. LPA observed all client bedrooms are clean and organized. LPA observed all client rooms had the required bedding and furniture. LPA observed the fire extinguisher upstairs was fully charged. LPA observed all bathrooms were clean and operational. Hot water in all the bathrooms measured 112.8 degrees Fahrenheit. LPA and Administrator toured the backyard. No bodies of water observed. There is a large plastic shed in the backyard and a one room building. Both are used for storage and kept locked. No obstacles or hazards observed in the backyard. Both exit gates are operational. LPA observed there is a table and chairs in the patio for clients to sit outside. There is a tree that provides some shade but there is no umbrella or covering for the table. LPA reviewed 4 client files, LPA observed that all the clients have notices verifying regular doctor visits but none of the clients had physician's reports (LIC 602s) completed in their files. LPA reviewed client medications. 3 out of the 4 clients are taking prescribed medications. LPA observed client 4 was missing 5 medications (3 PRN, 2 routine). LPA reviewed staff records. No discrepancies observed. Deficiencies are being cited per title 22 division six of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 4
Document Has Been Signed on 06/12/2024 11:49 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 06/12/2024 at 11:24 AM
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: FLORES ADULT RESIDENTIAL HOME
FACILITY NUMBER: 306003423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in 1 out of 4 client records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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4
Licensee agrees to update client 4's medications on hand and records to reflect the physician's current prescription orders for client 4. Licensee to submit proof of correction 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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/12/2024 11:49 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 06/12/2024 at 11:24 AM
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: FLORES ADULT RESIDENTIAL HOME
FACILITY NUMBER: 306003423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

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 4 out of 4 clients who do not have a medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Licensee agrees to have a medical assessment completed for each client by the POC due date. Licensee to forward proof to LPA.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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