306003505-12-1-2022-22-AS-SHAD-CLPVWJ-20221201154801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003505
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:48:05 PM

Document Has Been Signed on 12/01/2022 03:48 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:	JOHN 316 RESIDENCE CARE		FACILITY NUMBER:	306003505
ADMINISTRATOR:	JOHN/ROWENA BASILIO		FACILITY TYPE:	740
ADDRESS:	1023 N. WHITTIER STREET		TELEPHONE:	(714) 563-9524
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 3	DATE:	12/01/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	John Basilio		TIME COMPLETED:	04:00 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	This unannounced Plan of Corrections inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Annual inspection conducted on 11/17/22. LPA met with Administrator (AD) John Basilio and discussed the purpose of the inspection. During the inspection, LPA toured the facility and conducted health and safety checks on the 3 residents and observed no health and safety issues. LPA observed Staff #1 (S1) Amelia Taningco was not present. Type A Violation cited under Title 22 Regulation 87411(a) pertaining to sufficient and competent staff has been CLEARED. The plan of corrections stated that “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.” On 11/24/22, LPA received an update from AD stating that AD is working every day at the facility to provide care to the residents. During today’s inspection, LPA observed AD at the facility providing care and supervision to 3 residents who were present. Per AD, AD is still trying to hire additional staff, but at this point AD is the only staff proving care until AD’s wife recovers from her surgery. AD stated they are living at the facility and providing care to the residents 24/7 and are having groceries delivered so they are not absent from the facility at any time. LPA again provided a list of staffing agencies to AD and strongly advised that AD obtain additional staff from the staffing agencies. Type B Violation cited under Title 22 Regulation 87411(f) pertaining to staff records has been CLEARED. The plan of corrections stated that “Licensee agreed to find S1’s health screening and provide a copy to LPA on 11/24/22.”

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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: JOHN 316 RESIDENCE CARE	FACILITY NUMBER: 306003505
	VISIT DATE: 12/01/2022

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However, per AD, AD was unable to find S1’s health screening but terminated S1’s employment on 11/24/22 meaning that S1 was no longer a staff member and no longer needed a health screening. AD stated that S1 moved out of the facility on 11/30/22. During today’s inspection, LPA confirmed that S1 was not present and that S1 removed their belongings from their former room at the facility.

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

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC809 (FAS) - (06/04)

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