306003462-7-19-2022-22-AS-KSGH-CGGU4P-20220719151529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003462
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:15:42 PM

Document Has Been Signed on 07/19/2022 03:15 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:	OLIVERA RESIDENTIAL HOME		FACILITY NUMBER:	306003462
ADMINISTRATOR:	REYNALDO BALO		FACILITY TYPE:	740
ADDRESS:	24111 OLIVERA DRIVE		TELEPHONE:	(949) 460-0583
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 3	DATE:	07/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Reynaldo Balo, Administrator		TIME COMPLETED:	03:30 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 07/19/2022 at 1:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Reynaldo Balo, Licensee and Administrator after explaining the purpose of the visit. LPA observed a check-in station at the facility's entrance where visitors's temperatures are being documented. At approximately 1:45pm, LPA accompanied by licensee toured the inside and outside of the facility. There are currently three (3) residents in care, none of which are receiving hospice care. Residents are observed sleeping in their bedroom and appear clean and well taken care of. The six (6) bedrooms include all necessary components. The bathroom is equipped with grab bars and slip mats. Two (2) of the vacant rooms are restricted from access by the residents and are used for storage, as is the garage. These rooms are however filled with a large amount of clutter and should remain inaccessible to residents. Sharp instruments are stored in a kitchen drawer with a functional magnetic lock. LPA observed a sufficient supply of food and water, however the facility does not have an emergency supply of food and water on hand. There is a locked cabinet with a digital code lock for the central storage of medication, however at the time of the visit, the residents' medications are observed to be stored in the licensee's room which is not locked. Licensee subsequently placed the medication under lock during the visit. Cleaning supplies are secured in the locked attached garage and in a locked cabinet under the kitchen sink. A sufficient supply of linen is observed. LPA observed required department postings. Facility has an adequate supply of PPE. CONTINUED IN FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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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Document Has Been Signed on 07/19/2022 03:15 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

This section requires that "Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement is not met as evidenced by: The residents' medication was observed to be kept in the licensee's bedroom at the time of the visit in spite of the fact that a secure cabinet has been installed across the hall for secure storage.
	Deficient Practice Statement
1 2 3 4	Based on observation made during the visit, the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2022
	Plan of Correction
1 2 3 4	Licensee will ensure adequate and secure storage of the centrally stored medication in the dedicated cabinet secured by a code lock mechanism.

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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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: OLIVERA RESIDENTIAL HOME	FACILITY NUMBER: 306003462
	VISIT DATE: 07/19/2022

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CONTINUED FROM FORM LIC809

Licensee indicates that there has not been any staff actively employed at the facility since the month of November 2021 and that he has been running the facility alone since then. The licensee is currently in talks with a prospective buyer who has expressed interest in submitting a license application for the facility. LPA observes that no prospective application at that address has been submitted at the time of the visit and encourages the licensee to have the prospective buyer apply as soon as possible to account for the time needed to process and grant a new application. LPA additionally provides a consultation on the necessity to keep the license current and administrator certification active and valid until the licensing application of the prospective licensee gets granted as long as the facility is caring for residents.

LPA toured the outside of the facility. The two perimeter gates are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, a deficiency regarding the storage of medication is being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory on Infection Control Requirements was also issued. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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