306003515-3-6-2024-22-AS-RQUZ-D353LG-20240306172044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003515
Report Date: 03/06/2024
Date Signed: 03/06/2024 05:22:09 PM

Document Has Been Signed on 03/06/2024 05:22 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:	MARY'S ASSISTED HOME LIVING		FACILITY NUMBER:	306003515
ADMINISTRATOR:	MAUREEN SALONGA		FACILITY TYPE:	740
ADDRESS:	11642 DALE STREET		TELEPHONE:	(714) 537-0899
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 4	DATE:	03/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Jay Ramos, Caregiver and Maureen Solanga, Administrator		TIME COMPLETED:	05:30 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 today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called Administrator (AD) Maureen Solanga and explained the nature of the visit. (AD) Solanga arrived to the facility on or about 4:47pm. This facility is a Residential Care Facility for the Elderly and licensed to provide services to six (6) Non-Ambulatory Residents, and has a hospice waiver for two (2) residents. There are four (4) residents in care of which (2) two residents are receiving hospice care services. There are no active COVID-19 cases in the facility at this time. Administrator Maureen Solanga has an Administrator Certificate with expiration date of 10/24/2024. LPA Rosie Quiroz along with (CG1) toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed three of four residents in their bedroom resting and 1 of four residents in the living-room area with staff supervision. LPA Quiroz interacted and interviewed with staff and residents during today's visit. Between 3:16pm-3:25pm while conducting inspection tour of the kitchen area, LPA Quiroz observed expired canned food and food items with expiration dates varying from 4/2022- 1/15/2024. This was verified with(CG1) and (AD) Solanga upon arrival to the facility. (SEE LIC 809-D) LPA Quiroz observed emergency water; however due to expired items observed in pantry area, facility does not have a supply of emergency food readily available for residents in care. LPA Quiroz inspected resident's bedrooms and bathrooms. Water temperatures were recorded to be between 114.7-119.4 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. LPA Quiroz toured the outside of the facility and observed seating and shaded area backyard for residents and visitor's enjoyment in backyard area. CONTINUED ON NEXT LIC 809-C PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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 03/06/2024 05:22 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: MARY'S ASSISTED HOME LIVING	FACILITY NUMBER: 306003515
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

87202(a) All facilities shall maintain a fire clearance approved by the city, county and county fire department , or district providing fire protection services, or the state fire marshall. Prior to accepting or retaining any of the following types of persons, the applican or licensee shall notify the licensing agencyand obtain an appropriate fire clearance approved by the city, county, and county fire department, or district providing fire protection services, or the state marshall. This requirement is not met as evidenced by: Resident 4 has a bedridden status based on physician report dated 12/13/2022.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as evidenced by physician report dated 12/13/2022 for resident 4 in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	Facility will report bedridden status to fire department and CCLD. Licensee and/or Administrator will call and inform Resident 4's responsible party of bedridden status and relocate resident to a facility with bedridden capacity by 3/8/2024.

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) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2024 05:22 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: MARY'S ASSISTED HOME LIVING	FACILITY NUMBER: 306003515
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirement(b)(8): All food shall be of good quality. Commercial food shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: During today's visit, expired food items and canned food were obsreved to be expired ranging from 4/2022- 1/2024 expiration dates.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview), the licensee did not comply with the section cited above in as evidenced by having expired canned food and other food items readily available to residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	(AD) Solanga will discard all expired canned food on stock on today's date and purchase emergency food supply and submit proof of receipts to CCL by 3/7/2024.

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) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MARY'S ASSISTED HOME LIVING	FACILITY NUMBER: 306003515
	VISIT DATE: 03/06/2024

NARRATIVE

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CONTINUED...While reviewing 4 of 4 resident records, LPA Quiroz observed R4's physician report indicating bedridden status. This was verified with (CG1) and (AD) Solanga upon arrival to the facility. (SEE LIC 809-D and LIC 421-IM)
During today's visit, LPA Quiroz provided Consultation on Title 22, Infection control, Maintenance and Operation, Fire Clearance and General Food Service Requirements.

Citations were issued during today’s visit and Civil Penalty was assessed.

An exit interview was conducted with (AD) Solanga and a copy of this report, LIC 811-Confidential names, LIC 809-D pages, LIC 412-IM and Appeal Rights were provided to (AD) Solanga at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

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