306003443-9-25-2024-22-AS-KSGH-D9FSDG-20240925134705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003443
Report Date: 09/25/2024
Date Signed: 09/25/2024 01:47:38 PM

Document Has Been Signed on 09/25/2024 01:47 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ACTIVE SENIOR HOME CARE		FACILITY NUMBER:	306003443
ADMINISTRATOR:	BINTINTAN, AURICA		FACILITY TYPE:	740
ADDRESS:	26771 VIA VICTORIA		TELEPHONE:	(949) 380-1143
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Aurica Bintintan, Administrator		TIME COMPLETED:	01:45 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Administrator Aurica Bintintan was also present and assisted with the visit. During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with four private and one shared bedrooms in addition to two staff rooms for use by the live-in caregiving staff and administrator. There are five bathrooms throughout the facility, either accessible through the hallways or en-suite in the bedrooms. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. Multiple beds are observed to be equipped with full bed rails and another one with half rails. Physician orders and hospice plans of care reviewed as well as physician order for the half rails. Consultation provided. There are currently six residents admitted to the facility, four of which is receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was measured to be within acceptable temperature range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly however they are not systematically documented. Consultation provided. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been replaced in 2024. There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the property. The route of egress is free of obstructions. There are no bodies of water on the premises. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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 09/25/2024 01:47 PM - 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: ACTIVE SENIOR HOME CARE	FACILITY NUMBER: 306003443
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, the licensee did not comply with the section cited above as one resident has been assessed as bedridden upon admission in January 2024. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/26/2024
	Plan of Correction
1 2 3 4	Licensee will initiate the process to request an update visit from the Orange County Fire Authority before the plan of corrections 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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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

FACILITY NAME: ACTIVE SENIOR HOME CARE	FACILITY NUMBER: 306003443
	VISIT DATE: 09/25/2024

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CONTINUED FROM FORM LIC809
Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed six resident files and three staff files. Two staff and one resident interviews conducted. Resident records include all necessary components. All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training records, health screenings and CPR training are on file and up to date. Training provided meets the regulatory requirements for initial and annual training. Based on observation and records reviewed, one resident receiving hospice care is observed to be and have been assessed as bedridden. The current fire clearance for the facility does not include a provision for bedridden residents. Type A citation issued.

Based on the observations made during today’s inspection, one type A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Three Advisory Notes issued along with consultations provided to the licensee.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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