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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004063
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:50:42 PM


Document Has Been Signed on 11/15/2023 02:50 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:DALE B&C HOMEFACILITY NUMBER:
306004063
ADMINISTRATOR:SOPHEAP THONGFACILITY TYPE:
735
ADDRESS:8562 DAVMOR AVENUETELEPHONE:
(714) 537-8718
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 5DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Sopheap Thong - AdministratorTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Administrator (AD) Sopheap Thong.

The facility is a one-story home with three resident bedrooms, two resident bathrooms, kitchen, dining room, living room, staff room, den, back yard and attached two-car garage. LPA noted that the residents were away at day program during the inspection. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels. Hot water measured at 118.5 degrees Fahrenheit in the bathroom nearest all the bedrooms, 115.2 degrees Fahrenheit in the bathroom accessible from the living room. Facility has a supply of extra linen and hygiene supplies stored in the garage. LPA observed facility has emergency food and water supply stored in the garage. Backyard has seating area and several plants. Backyard also has an excess of unused/rusted yard equipment, wood and metal, exercise equipment, trash/recyclables and more. Medication, first aid kit and facility files are stored in locked cabinets. LPA reviewed three out of five resident files, three out of five resident medication and three personnel files. AD stated that they are communicating with client physicians to acquire copies of most recent visit summaries. LPA issued a technical assistance regarding medical visit documentation. LPA observed infection control plan was not accessible during visit. LPA observed the last disaster drill took place in 2022, LPA observed one resident did not have two current medications listed on their MAR. LPA observed facility to not be clean and sanitary.

Five deficiencies and two technical assistances were noted during today's visit. An exit interview was conducted and a copy of this report was provided to the administrator.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 11/15/2023 02:50 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as their infection control plan was not accessible at the time of inspection. This a potential health risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator stated they will email LPA a copy of the Infection Control Plan by the assigned POC due date of 12/15/2023.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as several gnats were visible near the toilet in one of the bathrooms. This poses a potential health risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator stated they will clean and sanitize the area observed to have insects around it. LPA will verify this correction via follow-up visit.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 11/15/2023 02:50 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the following instances: 1. Toilet seat is broken, 2. One Bedroom door has a hole, 3. Excessive dust and trash is visible on floor in bedrooms, 4. Backyard debris includes: unused/broken outdoor furniture, rusted metal yard tools/equipment, bags of recyclables, broken wood/glass, unsanitary jars of food. All of this poses potential health and safety risks to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator stated they will purchase and replace toilet seat, hire someone to fix the door or fix it themself, staff will work with clients to keep rooms free of dust and trash. Administrator will hire staff for a day to clear out the debris in the backyard. All of these tasks will be completed by assigned POC due date of 12/15/2023. LPA will confirm corrections via follow-up visit.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to the facility not conducting a disaster drill since 2022. This poses a potential safety risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator stated that the facility will hold a disaster drill and document it prior to the assigned POC due date. LPA will confirm this correction via record review.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 11/15/2023 02:50 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070

The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. (b) Each record must contain information including, but not limited to record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication and record review, the licensee did not comply with the section cited above in one instance. One resident's medication record did not include two medications the resident is currently taking. This poses a potential health risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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During the inspection, Administrator decided to call the pharmacy to request the second page of the client's medication record. Administrator stated that they will acquire the document and include it in the client's medication record by the assigned POC due date on 12/15/2023. LPA will verify this correction via follow-up visit.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6