306003566-7-17-2024-22-AS-MRIO-D79PUK-20240717113736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003566
Report Date: 07/17/2024
Date Signed: 07/17/2024 11:37:46 AM

Document Has Been Signed on 07/17/2024 11:37 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
Lookup Error,
, CA

FACILITY NAME:	FRANCEL GUEST HOME II		FACILITY NUMBER:	306003566
ADMINISTRATOR:	FRANCISCO BALISI		FACILITY TYPE:	740
ADDRESS:	9441 HOUSTON AVENUE		TELEPHONE:	(714) 844-2527
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	14	CENSUS: 11	DATE:	07/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Joclyn Late and Francisco Balisl		TIME COMPLETED:	11:50 AM

NARRATIVE

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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with caregiver Jocylyn Late and was granted entry to the facility. Licensed capacity is (14) current census (11). LPA was accompanied by caregiver Jocylyn Late and Administrator Francisco Balisl to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated office for client/staff files.

During facility tour, LPA observed outdoor activity area not easily accessible for residents in care. Outdoor patio was surrounded by large boxes, bed mattresses and pervious residents’ wheelchairs. Administrator had agreed to relocate items to their storage space.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: 951-255-6866
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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 07/17/2024 11:37 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
Lookup Error,
, CA

FACILITY NAME: FRANCEL GUEST HOME II	FACILITY NUMBER: 306003566
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in 1 out of the 3 residents did not have the date and time the PRN medication was taking. S1 stated they did not document correctly when the PRN was provided which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	The Administrator has agreed to provide medication training for all staff and will send LPA a copy of their training. The Administrator has also agreed to read regulation entirely and send LPA a self-certified letter that the regulation 87465(d)(3) was read and understood.

Type A

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 3 record review did not have an updated medical assesment. R1 last medical assesment was conduct in 2021 as which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	The Administrator has also agreed to read regulation entirely and send LPA a self-certified letter that the regulation 87705(c)(5)(A) was read and understood. The Administrator will also send proof they have schedule a medical appointment for R1.

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: 951-255-6866
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/17/2024 11:37 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
Lookup Error,
, CA

FACILITY NAME: FRANCEL GUEST HOME II	FACILITY NUMBER: 306003566
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(h)(2)

Planned Activities

(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above having outdoor acitvity area not easily accessible to residents. Outdoor patio was surrouned by large boxes, bed mattresses and pervious residents’ wheelchairs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2024
	Plan of Correction
1 2 3 4	The Administrator has also agreed to read regulation entirely and send LPA a self-certified letter that the regulation 87219(h)(2) was read and understood. Administrator has also agreed to send LPA proof the outdoor activity areas are accessible to the residents.

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: 951-255-6866
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: FRANCEL GUEST HOME II	FACILITY NUMBER: 306003566
	VISIT DATE: 07/17/2024

NARRATIVE

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Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, and needs and services plans. 1 out the 3 residents did not have their annual medical assessment, which is required for dementia residents. R1 last medical assessment was conduct in 2021. LPA reviewed (3) resident medications. 1 out of the 3 residents prn medication, did not have the exact date and time it was provided.

LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, two (2) Type A and one (1) Type B deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Francisco Balisl. Along with a copy of appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: 951-255-6866
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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