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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004063
Report Date: 10/17/2024
Date Signed: 10/17/2024 01:47:03 PM

Document Has Been Signed on 10/17/2024 01:47 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DALE B&C HOMEFACILITY NUMBER:
306004063
ADMINISTRATOR/
DIRECTOR:		SOPHEAP THONGFACILITY TYPE:
735
ADDRESS:8562 DAVMOR AVENUETELEPHONE:
(714) 537-8718
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Sopheap ThongTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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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. LPA Tea was greeted and granted entry into the facility by Licensee(LE)/Administrator (AD), Sopheap Thong and explained the reason for the visit. Facility is licensed for 6 ambulatory clients. Currently there are six clients.
LPA Tea reviewed six client files and two staff files. There were discrepancies noted in the review of resident and staff files.
LPA Tea and AD Thong toured the facility at around 9:45 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 3 shared client bedrooms, 1 caregiver room, 3 bathrooms, living room, dining room, family room and kitchen and attached garage. LPA observed smoke detectors/carbon monoxide in client bedrooms and they are operational. There are cameras with no audio recording in the common area for security purposes. Client bedrooms had the required furniture, and closet/drawer space to accommodate each resident comfortably. Mold was observed in one bedroom ceiling. Linen closet needed more linens, sheets and comforters to meet client needs. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured at 119.4 F degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. 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 Tea observed sharps and toxins not stored securely in the kitchen area. AD Thong secured toxins and sharps securely and made them inaccessible to clients after LPA Tea's observation. One stove burner was not working properly. The fire extinguisher in the dining room was fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating in the backyard. LPA observed emergency food and water supply in the garage.

Continuation of annual inspection on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 7
Document Has Been Signed on 10/17/2024 01:47 PM - It Cannot Be Edited


Created By: Michael Tea On 10/17/2024 at 12:17 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: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 LPA observations fruit flies were flying around the dining room table from unwashed cups. This poses as an immediate health and safety risk to clients in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee cleared and clean the cups that had the infestation. LPA advise that it's also licensee/administrator responsibility to maintain cleanliness in the facility to prevent fruit flies and pest.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose 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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LPA observed toxins in the kitchen out in the open, not locked or made to be inaccessible to clients in care. Knives were stored underneath the stove burner and out in the open around the kitchen sink, not locked and secured. This poses an immediate health and safety issue for clients in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee locked knives, sharps inside the medicine cabinets temporarily and will find a place to store them and have them locked. Toxins are locked in the caregivers room where clients have no access and the room is locked.
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
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/17/2024 01:47 PM - It Cannot Be Edited


Created By: Michael Tea On 10/17/2024 at 12:17 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: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA observations of the facility, resident rooms are unclean and have grime, one resident room has mold around the ceiling area, one kitchen stove burner is not working. This poses as a potential health and safety risk to clients in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will show proof to LPA that work orders are being prepared to take care of the disrepair in the facilities. And provide proof of completion of repairs to LPA.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during facility tour, one of the bathrooms has a broken fan making a loud noise. Also there is a water leakage coming from the toilet that is covered with a towel to prevent water leakage. This poses as a potential health and safety risk to clients in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will provide proof of repairs 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
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/17/2024 01:47 PM - It Cannot Be Edited


Created By: Michael Tea On 10/17/2024 at 12:17 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: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(g)
Fixtures, Furniture, Equipment, and Supplies
(g) The licensee shall provide linens of various kinds necessary to meet the program of services being offered by the facility and the requirements specified in Chapters 2 through 7.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's observation of the linen closet, there were not enough linens, sheets or comforters for the clients. This poses as a potential health, safety, and personal rights risk to clients in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will purchase linens and provide proof to LPA by POC due date.
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's review of staff records there are not current staff training for this year. Last training was done 2023. This poses as a potential health and safety risk to clients in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will provide completion of required annual training for staff 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
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/17/2024 01:47 PM - It Cannot Be Edited


Created By: Michael Tea On 10/17/2024 at 12:17 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: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's review of client records, one client does not have a current physician's report on file. Another client has an incomplete physician's report on file. This could pose as a potential health and safety risk to the clients in care..
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will provide completed physician's report for clients by POC due date to LPA.
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 LPA's record review there are no documentations of diaster drills conducted despite licensee explaining that she did conduct them and did not record or log the drills. This could be a potential safety risk to clients in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will create a seperate log book and provide proof of a conducted drill by POC due date to LPA.
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
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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: DALE B&C HOME
FACILITY NUMBER: 306004063
VISIT DATE: 10/17/2024
NARRATIVE
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At the time of the visit, clients were coming back from the day program and eating lunch..
LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the dining room area. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Licensee Sopheap Thong and a copy of these reports were given to the facility along with a copy of the LIC858; 859;809-D, 9102 and Appeal Rights
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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