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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003460
Report Date: 09/02/2022
Date Signed: 09/16/2022 08:55:24 AM


Document Has Been Signed on 09/16/2022 08:55 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BASIA RESIDENTIAL CAREFACILITY NUMBER:
306003460
ADMINISTRATOR:BARBARA MANCZYKFACILITY TYPE:
740
ADDRESS:23931 GOWDY AVENUETELEPHONE:
(949) 768-0452
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 3DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Facility Administrators-
Barbara Manczyk, Joanna Manczyk		TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 3 staff were on duty, including facility administrators (ADs) Barbara Manczyk and Joanna Manczyk. As of 9/2/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was also observed in the facility hallway. LPA De Perio observed the Administrator's Certificate for Barbara Manczyk which expires on 11/7/23, and Joanna Manczyk, which expires on 4/22/24.

LPA De Perio toured the interior and exterior portions of the facility with ADs. The facility is a two level structure and is licensed for 6 non-ambulatory residents, 0 bedridden and 4 hospice. For this visit, there are a total of 3 residents in care, 0 on hospice and 0 bedridden. LPA De Perio verified that second level of facility is not for resident use, but is utilized for staff. LPA De Perio observed no residents residing on second floor. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 115.0 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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: BASIA RESIDENTIAL CARE
FACILITY NUMBER: 306003460
VISIT DATE: 09/02/2022
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LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage and facility hallway. Medications were locked in the hallway cabinet. Toxins were also observed to be locked in the garage and inaccessible to residents.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, of which one is only used as an exit, and is self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with ADs. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with ADs to review, print and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised ADs to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with ADs and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC809 (FAS) - (06/04)
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