306004273-12-2-2024-22-AS-KSGH-DBKSNK-20241202130141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004273
Report Date: 12/02/2024
Date Signed: 12/02/2024 01:02:44 PM

Document Has Been Signed on 12/02/2024 01:02 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:	NANA'S GARDEN		FACILITY NUMBER:	306004273
ADMINISTRATOR/ DIRECTOR:	BRIGITTE/DONALD FISK		FACILITY TYPE:	740
ADDRESS:	26531 NACCOME		TELEPHONE:	(949) 770-2722
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Brigitte Fisk, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:10 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Brigitte Fisk was notified via telephone and arrived later to assist with the inspection. There are currently six residents in care, one of which is receiving hospice care. LPA observed residents participating in activities in the facility’s common areas and relaxing in their respective bedrooms as well as having lunch in the dining area. LPA accompanied by facility caregiver toured the physical plant. The facility is a one-story house with an attached garage. The facility has six private resident bedrooms, three of which equipped with an en-suite bathroom and three others sharing a central bathroom. All bedrooms appeared clean and sanitary. LPA observed all the resident bedrooms has the required furnishings. One resident on hospice has a bed equipped with full rails and another resident has half-rails in place. All corresponding physician orders and hospice plans of care present on file and reviewed. All bathrooms appear clean and sanitary. Bathrooms were equipped with grab bars and non-slip mats. Hot water temperature measured within the required temperature range. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. LPA observed knives locked in a secure block in the kitchen. A fire extinguisher is verified to be charged and has been maintained in 2024. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked cabinet in the dining room. The locking mechanism however appears to not be operational at the time of the visit, type B citation issued. The attached garage is inaccessible to residents and is used for storage and for laundry. Cleaning supplies are located in the garage. CONTINUED ON FORM LIC809-C

Sheila Santos	TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
	DATE: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NANA'S GARDEN	FACILITY NUMBER: 306004273
	VISIT DATE: 12/02/2024

NARRATIVE

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CONTINUED FROM FORM LIC809
LPA and caregiving staff toured the outside of the facility and observed it to be free of obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on both sides of the property are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed six resident records and reviewed all necessary components. All necessary documents observed and present. Medical assessments have been updated in a timely manner. LPA reviewed resident medication records. No discrepancies were observed. LPA reviewed two staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Infection Control and Emergency and Disaster plans were both reviewed and are complete and accurate. Fire and emergency drills are conducted quarterly and documented as required.

Based on the observations made during today’s visit, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/02/2024 01:02 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NANA'S GARDEN	FACILITY NUMBER: 306004273
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview, the licensee did not comply with the section cited above as the medication central storage locking mechanism was not functional at the time of the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee will replace the locking mechanism and provide documentation of the repair to LPA before the plan of corrections due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sheila Santos	TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
	DATE: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC809 (FAS) - (06/04)

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