306004176-8-25-2022-22-AS-ETAA-CHMPQ8-20220825113042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004176
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:30:51 AM

Document Has Been Signed on 08/25/2022 11:30 AM - 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:	SAM'S HOMECARE		FACILITY NUMBER:	306004176
ADMINISTRATOR:	JUHAYNA DIAZ		FACILITY TYPE:	740
ADDRESS:	18900 SEABISCUIT RUN		TELEPHONE:	(714) 312-0054
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 6	DATE:	08/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Rosallie Gabriel, Francisco Gabriel, Juhayna Diaz		TIME COMPLETED:	11:40 AM

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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Rosallie” Sally” Gabriel and Francisco “Gaby” Gabriel and stated the purpose of this visit. Administrator Juhayna Diaz arrived during the visit and provided assistance. The facility is a two-story structure and licensed for six non-ambulatory residents with a hospice wavier for five. This facility offers Residential Care for the Elderly/Hospice. At about 9:20 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed six residents in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. There were two shared resident rooms and two private resident rooms. The second floor is for staff only and contains an office and staff rooms. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and hot water was measured at 116.9 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; LPA did notice a plant in the center of the walkaway towards the back gate. Staff was made aware of this and immediately removed plant. LPA also notice a palate and large wooden stick in the backyard that was not obstructing any pathway. Administrator informed LPA that they had just moved some furniture and will be removing palate and large stick from the premises. LPA also informed Administrator of apparent rust on backyard gate.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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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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: SAM'S HOMECARE	FACILITY NUMBER: 306004176
	VISIT DATE: 08/25/2022

NARRATIVE

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Facility offers a 4-car garage mainly used as storage with operational washers/dryer. Garage also contained 2 cars. Medications and toxins where locked and kept away from residents. Kitchen was in good repair. Administrator did make LPA aware of clicker on stove not working properly and will have maintenance come in next week to fix the issue. LPA made Administrator aware of late annual fees. Administrator paid annual fee online and received a confirmation number. LPA Tapia reviewed the COVID 19 mitigation plan and the emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to 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.

For this visit, no deficiency was noted in areas observed and two advisories were issued.

LPA Tapia conducted an exit interview with Administrator Juhayna Diaz and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC809 (FAS) - (06/04)

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