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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003775
Report Date: 08/20/2024
Date Signed: 08/20/2024 11:45:25 AM


Document Has Been Signed on 08/20/2024 11:45 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HEART TO HEART CARE HOME FOR ELDERLYFACILITY NUMBER:
306003775
ADMINISTRATOR:IMELDA CANLASFACILITY TYPE:
740
ADDRESS:3101 JEFFERSON AVENUETELEPHONE:
(714) 617-4708
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Imelda CunninghamTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:00 AM, LPA Tea was greeted and granted entry into the facility by house manager, Angeline Delacruz and explained the reason for the visit. The administrator (AD) Imelda Cunningham arrived shortly to assist with the visit. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for four. Currently there are six residents, of which three are on hospice during today's visit.

Around 8:20 AM, LPA Tea reviewed six resident files and three staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted in July 5, 2024. AD Cunningham administrator certificate is currently expired however administrator has complied with all course work and is pending renewal at this time.

LPA Tea along with AD Cunningham toured the facility at 9:19 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 5 resident bedrooms, 1 staff room, 2 bathrooms, living room, dining room, kitchen and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured around 110 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink and a shed in the backyard. The fire extinguisher was fully charged in the kitchen area. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard.

Annual continuation on LIC809-C

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HEART TO HEART CARE HOME FOR ELDERLY
FACILITY NUMBER: 306003775
VISIT DATE: 08/20/2024
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There are two exit gates that are self-latching and operational on both sides of the house. LPA observed PPE supplies, emergency food and water stored in the garage. Facility provides activities based on their personal choice. Residents walk around the house and do some gardening in the yard. At the time of the visit, LPA observed residents having breakfast and lounging in the living room watching television and movies.

At 9:39 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Imelda Cunningham and a copy of this report LIC809, along with the 809-C, LIC858, and LIC859 were read and provided to the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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