<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003432
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:03:15 PM

Document Has Been Signed on 01/09/2025 04:03 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EMBASSY RESIDENTAL CAREFACILITY NUMBER:
306003432
ADMINISTRATOR/
DIRECTOR:		CORA KONFACILITY TYPE:
735
ADDRESS:1809 W. EMBASSY AVENUETELEPHONE:
(714) 758-3677
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 3DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:03 PM
MET WITH:Facility Staff - Nenita MandapatTIME VISIT/
INSPECTION COMPLETED:
04:17 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
Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted an unannounced annual required visit. LPA arrived at the facility and was greeted by Facility staff Nenita Mandapat and explained the nature of the visit. The facility is a one-story home with two client rooms, one bathroom, two staff rooms, kitchen, dining room, living room, backyard with covered patio, and 2-car garage.

All client rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels. LPA observed broken parts in the client bathtub. A deficiency is being issued. LPA observed the facility to be clean, safe and sanitary. LPA observed the fire extinguisher was serviced on 1/24/2024 according to the attached service tag. Smoke/Carbon Monoxide detectors were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and garage. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a cabinet in the kitchen. Exit gate is unlocked and self-latching. LPA observed exit gates to be unobstructed. LPA reviewed all three client files. Client files contained all the necessary elements. LPA reviewed two staff files. Based on record review, LPA observed the facility does not have the following: an non-COVID infection control plan or a current emergency disaster plan. Two Technical Violations are being issued. LPA also reviewed P&I and medication for three clients. LPA interviewed two staff and one client.

Based on the observation made during today’s visit, two deficiencies and two technical violations are being issued per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility staff and a copy was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 01/09/2025 04:03 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 01/09/2025 at 03:38 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: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above due to the presence of broken parts in the client bathtub.
POC Due Date: 01/23/2025
Plan of Correction
1
2
3
4
Facility staff stated they would ensure the broken parts of the client bathtub get repaired by the POC due date. Facility staff stated they will notify LPA upon completion of repairs.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to the presence of a disaster drill log showing the facility conducted 3 out of 4 required disaster drills in 2024.
POC Due Date: 01/23/2025
Plan of Correction
1
2
3
4
Facility staff stated they will conduct a disaster drill and create a record for the drill and email the record to the LPA by the POC due date. Facility staff stated they will email LPA with a list of 3 dates additional dates the plan to conduct their quarterly disaster drills in 2025 by the assigned POC due date. LPA stated the drills do not have to occur on the exact dates provided to the LPA, but reminded the AD that the drills must occur quarterly.
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:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4