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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003971
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:35:28 PM

Document Has Been Signed on 09/25/2024 12:35 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NANCITA HOMEFACILITY NUMBER:
306003971
ADMINISTRATOR/
DIRECTOR:		AARON RESURRECCIONFACILITY TYPE:
735
ADDRESS:713 N. NANCITA STREETTELEPHONE:
(714) 220-2657
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Ariel Resurreccion, Louise IgisaiarTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joseph Alejandre and Samer Haddadin made an unannounced to visit to conduct the required annual inspection. LPAs were greeted and granted entry to the facility. LPAs met with administrator Ariel Resurreccion and explained the reason for the visit. The Administrator's certificate expires March 11, 2025. LPAs toured the facility with the administrator. The facility is a one story home with seven bedrooms and two restrooms, in which 5 of the bedrooms (1 bedroom is currently vacant) are clients rooms, living room, dining room, kitchen and an attached 2 car garage. LPAs observed the kitchen is clean and organized. The knives and sharp objects are kept locked under the sink. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The 5 burner stove lights unassisted. The fire extinguisher in the dining room is fully charged. LPAs observed the client rooms are clean and organized. LPAs observed both bathrooms are clean and operational. Hot water measured 114.9 to 116.6 degrees Fahrenheit. LPAs observed the garage is used for storage of food and supplies. LPAs observed emergency food and water stored in the garage and in the hall closet. Medication is kept locked in the hall closet. No obstacles or hazards observed in the facility. LPAs toured the backyard. There are 2 metal sheds in the backyard. Both sheds are used for storage of old furniture and tools. Both sheds are kept locked. The exit gates are operational. No bodies of water observed. No obstacles or hazards observed in the backyard. The last fire drill was conducted September 02, 2024. Smoke detectors and carbon monoxide detector tested operational. LPAs inspected the first aid kit. The first aid kit has all the required elements.
LPAs reviewed 5 staff files. All 5 staff have the required training including first-aid training. LPAs reviewed all 4 clients medications. 2 out of 4 clients are missing PRN medications. Client 1 is missing PRN Loatadine 10 mg. Client 4 is missing PRN Diphenylamine 50 mg and PRN Lorazepam 1 mg . LPAs reviewed all clients' P& I monies, no discrepancies observed. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 09/25/2024 12:35 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 09/25/2024 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NANCITA HOME
FACILITY NUMBER: 306003971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in 2 out of 4 clients, Client 1 is missing PRN Loatadine 10 mg. Client 4 is missing PRN Diphenylamine 50 mg and PRN Lorazepam 1 mg, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee agrees to have all client medications that are prescribed, including PRNs. Licensee to submit proof of correction to LPA by POC due date
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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