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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003505
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:30:56 AM


Document Has Been Signed on 11/17/2022 11:30 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:JOHN 316 RESIDENCE CAREFACILITY NUMBER:
306003505
ADMINISTRATOR:JOHN/ROWENA BASILIOFACILITY TYPE:
740
ADDRESS:1023 N. WHITTIER STREETTELEPHONE:
(714) 563-9524
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 4DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Amelia Taningco, John BasilioTIME COMPLETED:
11:45 AM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Amelia Taningco and discussed the purpose of the inspection. Administrator (AD) John Basilio arrived during the inspection. During the inspection, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen and observed the following:

LPA observed there was 1 staff present. LPA observed 3 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

During the inspection, LPA observed the following: S1 was not able to fully assist LPA with the inspection, S1 was only able to walk slowly and with difficulty, S1’s hands shake when S1 tries to use the phone, S1 was not aware of where information was kept at the facility, S1 did not appear physically able to fully provide care to the residents, S1 was not fully aware, and S1 was the only staff present. AD stated that S1 is 72 or 73 years old, that S1 has been the main staff for only a short time due to hospitalization of the previous main staff on 10/29/22, that AD is trying to get a “better” staff than S1, but that AD generally comes to the facility almost every day and stays all day to provide care. AD stated that AD was not present at the facility when LPA arrived because AD’s wife was hospitalized on 11/14/22 and he was at the hospital and that his wife’s hospitalization has limited his ability to be at the facility. LPA interviewed 3 residents who stated S1 has been the main staff for a few weeks and that AD comes most days and helps for 3 to 6 hours on those days, but that AD previously worked full time at the facility before his wife was hospitalized. One resident stated that S1 does provide care, but cannot provide all types of care, and two residents stated that S1 does a good job and there are no issues.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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 5


Document Has Been Signed on 11/17/2022 11:30 AM - 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: JOHN 316 RESIDENCE CARE
FACILITY NUMBER: 306003505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and documents, the licensee did not ensure that 1 staff’s health screening was present at the facility, which poses a potential health and safety risk to persons in care.
POC Due Date: 11/24/2022
Plan of Correction
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Licensee agreed to find S1’s health screening and provide a copy to LPA on 11/24/22.

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 LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


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: JOHN 316 RESIDENCE CARE
FACILITY NUMBER: 306003505
VISIT DATE: 11/17/2022
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LPA requested S1’s health screening but AD was not able to produce the health screening. AD stated that effective immediately and until AD’s wife leaves the hospital, AD will begin living at the facility, will only leave the facility to visit his wife in the hospital, will not leave S1 unsupervised for more than 3 hours at a time, and will not be out of the facility more than 5 hours a day. AD stated that his wife will leave the hospital by 11/21/22 and no longer need AD’s help and that AD will be back at the facility full time starting on 11/21/22. LPA provided a list of staffing agencies to AD and strongly advised that AD obtain additional staff from the staffing agencies.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA requested and reviewed the resident roster, staff roster, resident files, staff files, emergency plan, COVID-19 mitigation plan, and Infection Control Plan. LPA provided technical assistance regarding N95 Fit Testing and facility closure procedures.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/17/2022 11:30 AM - 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: JOHN 316 RESIDENCE CARE
FACILITY NUMBER: 306003505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)


87411 Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not ensure staff were sufficient and competent as the only staff present at the facility was not fully capable of providing care to the residents, which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Licensee agreed that effective immediately and until AD’s wife leaves the hospital, AD will begin living at the facility, will only leave the facility to visit his wife in the hospital, will not leave S1 unsupervised for more than 3 hours at a time, and will not be out of the facility more than 5 hours a day. Licensee agreed to provide an update to LPA on 11/24/22 on AD’s return to full time at the facility, the current staffing situation, and future staffing plans.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5