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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003823
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:47:25 PM


Document Has Been Signed on 10/14/2022 03:47 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:ADRIANA ELDERLY CARE HOME IVFACILITY NUMBER:
306003823
ADMINISTRATOR:MENDOZA, ADRIANAFACILITY TYPE:
740
ADDRESS:24851 ARGUS DRIVETELEPHONE:
(949) 600-5734
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Facility Administrator - Richard MendozaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Richard Mendoza about visit. AD Mendoza arrived to facility at 2:22 PM. As of 10/14/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted in the entrance of the facility and in the kitchen hallway. The PUB475 "See Something, Say Something" poster was also observed at the entrance and in the facility hallway. AD R. Mendoza has not received the renewed certificate, however stated to LPA De Perio that the renewal fee has been paid. NOTE: Per AD R. Mendoza, renewal fee was submitted to bank via business check. AD R. Mendoza stated that he would obtain a copy of the renewal fee from bank and submit it to LPA De Perio on or by 10/21/22. LPA De Perio observed the Administrator's Certificate for Adriana Mendoza, which expires on 4/6/2023.

LPA De Perio toured the interior and exterior portions of the facility with staff on duty (S1). The facility is a single level structure and is licensed for for six residents, of which 6 may be bedridden and a hospice waiver for 6. For this visit, there are a total of 5 residents in care, of which 0 are bedridden and 0 on hospice. There are a total of 5 bedrooms, of which 5 are private, and 1 is shared and no room is designated for staff use. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 5 restrooms in the facility. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 107.9 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care and located in a kitchen drawer. Fire extinguisher was charged, mounted and located in the kitchen.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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Document Has Been Signed on 10/14/2022 03:47 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: ADRIANA ELDERLY CARE HOME IV
FACILITY NUMBER: 306003823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms, and other items which could post a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee failed to lock disinfectants, cleaning solutions, poisons, and other items which could post a danger. LPA observed cleaning supplies and disinfectants stored in an unlocked cabinet located in the laundry room, of which the laundry room is unlocked at all times. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Licensee will lock and ensure that all toxins and disinfectants are inaccessible to residents in care. AD removed all disinfectants and transferred them in a locked cabinet. Threat reduced. Licensee will comply with the POC on or by 10/28/2022 and submit proof to assigned LPA and Community Care Licensing.
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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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: ADRIANA ELDERLY CARE HOME IV
FACILITY NUMBER: 306003823
VISIT DATE: 10/14/2022
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LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance of the facility. Facility had back-up emergency food and water supply, located in a kitchen pantry. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in a hallway cabinet. Medications were locked in a cabinet and inaccessible to residents in care. There is a laundry room of which does not have a lock, and has two cabinets that store disinfectants and toxins. The bottom part of the cabinet is locked, however, the top portion of the cabinet does not have a lock.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is 1 gate in the backyard, which is self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Mendoza. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Mendoza to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Mendoza.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA De Perio advised AD Mendoza to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 3 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: ADRIANA ELDERLY CARE HOME IV
FACILITY NUMBER: 306003823
VISIT DATE: 10/14/2022
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LPA De Perio conducted an exit interview with AD Mendoza and a copy of this report, regulations discussed and Appeal Rights were provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5