306003841-1-30-2024-22-AS-KLYN-CZYRB8-20240130115219

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003841
Report Date: 01/30/2024
Date Signed: 01/30/2024 04:18:33 PM

Document Has Been Signed on 01/30/2024 04:18 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:	A PERICLES ELDERLY CARE HOME		FACILITY NUMBER:	306003841
ADMINISTRATOR:	LUIS GAITAN		FACILITY TYPE:	740
ADDRESS:	25822 PERICLES		TELEPHONE:	(949) 859-2811
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Concepcion Jimenez		TIME COMPLETED:	12:15 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	Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to A Pericles Elderly Care Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with CEO Concepcion Jimenez. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 4 residents present. There are three residents on hospice during today's visit. Luis Gaitan has an Administrator Certificate expiring on 05/06/2025. Administrator Lisa Branson arrived during the visit. LPA Lyman along with Concepcion Jimenez toured the facility at 9:07 AM. Facility appears to be clean, safe, and sanitary. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of five resident bedrooms, one resident bathroom, one office area, one shared hall bathroom, staff room, living room, dining room, and kitchen. 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 between 107.2 and 107.4 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene and cleaning supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. 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. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. At 9:30 AM, LPA observed the exit gate is in need of repair (photo). LPA observed emergency water supply on-site. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 11/12/2023. Facility provides activities in the form of games and exercise. CONT ON LIC 809C DATED 01/30/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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

FACILITY NAME: A PERICLES ELDERLY CARE HOME	FACILITY NUMBER: 306003841
	VISIT DATE: 01/30/2024

NARRATIVE

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At 10:00 AM, LPA reviewed five resident files and four staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of health screen/TB, and criminal record clearance. Three out of four staff do not have proof of training in the file. At 10:30 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited weekly by staff. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2024 04:18 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: A PERICLES ELDERLY CARE HOME	FACILITY NUMBER: 306003841
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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. The exit gate is in need of repair. This poses a potential health and safety risk to persons in care.
	POC Due Date: 02/13/2024
	Plan of Correction
1 2 3 4	Licensee to repair gate and forward proof to LPA by POC due date.

Type B

Section Cited

CCR

87412(c)

Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 three out of four staff records which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/13/2024
	Plan of Correction
1 2 3 4	Licensee to provide training to staff and maintain in the file. Licensee to forward proof to LPA by POC due date.

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: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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