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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003432
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:06:34 PM

Document Has Been Signed on 03/24/2022 03:06 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:EMBASSY RESIDENTAL CAREFACILITY NUMBER:
306003432
ADMINISTRATOR:CORA KONFACILITY TYPE:
735
ADDRESS:1809 W. EMBASSY AVENUETELEPHONE:
(714) 758-3677
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Eduardo Eleazar, caregiver
Corazon Eleazar, caregiver		TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Andrea Mendivil made an unannounced visit to the facility in order to conduct a required annual inspection. LPAs arrived at facility, were greeted and granted entry by caregiving staff after explaining the purpose of the visit. Administrator Cora Kon is currently away on vacation and unable to assist with today's visit.

At approximately 1:25pm, LPAs accompanied by caregiver Eduardo Eleazar toured the inside and outside of the facility. There are currently four (4) clients in care. Clients are observed to be relaxing in their bedroom or in the common areas are appear well taken care of. Two of the shared bedrooms include all necessary components and sufficient quantity of linen is observed. A third shared bedrooms does not include any chairs, and the ability to accommodate additional furniture is observed to be limited. Bathrooms are equipped with grab bars and slip mats. Cleaning supplies, sharp instruments and toxic substances are stored in locked cabinets and drawers.

LPAs observed the facility has COVID-19 Precautions posters and required department postings. However hand washing signs are not being displayed in the clients' bathrooms. Facility has an adequate supply of PPE and emergency supplies. A LIC808 Mitigation Plan has been submitted on 07/12/2021.

LPAs observed a sufficient supply of food and water. A 30-day supply of medication is stored and locked in a kitchen cabinet. LPAs toured the outside of the facility. Outdoor furniture is present for the client's enjoyment in the backyard. The gate by the side of the house is self-latching but cannot easily be opened in an evacuation as it is equipped with a padlock on the latch. Caretaker is reminded that evacuation gates are required to be kept unlocked at all times. Caregiver Eduardo Eleazar indicates that the gate is kept locked per the administrator's request in response to a client's in care tendency to elope. This deficiency is associated with the assessment of an immediate civil penalty of $500.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EMBASSY RESIDENTAL CARE
FACILITY NUMBER: 306003432
VISIT DATE: 03/24/2022
NARRATIVE
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In the absence of the administrator, emergency procedures and reporting are observed to be unclear for caregiving staff. The administrator's sister, also associated with the facility is designated to exercise the continuity of administrator duties as defined by Section 85064 of the California Code of Regulations. While inquiring on the Infection Control procedures and talking to one of the clients in care, it appears at least one instance of a client testing positive for COVID was not reported to Community Care Licensing.

Based on the observations made during today’s visit, two (2) deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and an additional Technical Advisory is being issued. An immediate penalty is also assessed at this time This report was reviewed with facility representative and a copy of this report and appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2022 03:06 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 03/24/2022 at 02:21 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: EMBASSY RESIDENTAL CARE
FACILITY NUMBER: 306003432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed both exit gates are secured. One gate is secured with a padlock and one gate is secured. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
POC Due Date: 03/24/2022
Plan of Correction
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Licensee removed lock during 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2022 03:06 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 03/24/2022 at 02:43 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: EMBASSY RESIDENTAL CARE
FACILITY NUMBER: 306003432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(1)(H)
Reporting Requirements Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (H) Epidemic outbreaks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observations and interview of staff and client conducted during today's visit , the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Licensee will ensure the adequate and timely reporting of any events specified by Section 80061 of the California Code of Regulations.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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