306004296-4-6-2022-22-AS-PVEZ-CD8UNM-20220406154410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004296
Report Date: 04/06/2022
Date Signed: 04/06/2022 03:44:15 PM

Document Has Been Signed on 04/06/2022 03:44 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PIERCE ADULT RESIDENTAL CARE HOME		FACILITY NUMBER:	306004296
ADMINISTRATOR:	ROMMEL MENDOZA		FACILITY TYPE:	735
ADDRESS:	3112 PIERCE AVENUE		TELEPHONE:	(714) 556-5102
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6		CENSUS: 6	DATE:	04/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:	Jaime Tan - Direct Support Professional Gino Manaloto - Lead Direct Support Professional		TIME COMPLETED:	03:55 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	Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Pierce Adult Residential Care Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Direct Support Professional (DSP) Jaime Tan. Lead DSP Gino Manaloto arrived later to assist with the visit. The facility is licensed for 4 ambulatory and 2 non-ambulatory clients. There are currently 6 clients living in the facility. DSP Manaloto did not know the date when the last emergency disaster drill was conducted at the facility. At 2:06 PM LPA Velazquez conducted a tour of the physical plant along with DSP Manaloto. The 1 story home consists of 4 client bedrooms and 1 bathroom. There are 2 staff bedrooms with 1 staff bathroom. The facility also has a living room, dining area, and kitchen. The 6 clients present in the facility appeared well-groomed and well cared-for. The client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathroom was checked. Client bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez and DSP Manaloto observed the surface of the bathtub had black stains. LPA Velazquez tested the hot water temperature in the client bathroom and the temperature measured at 102.9 degrees Fahrenheit. LPA Velazquez inspected the kitchen along with DSP Manaloto. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit but LPA and DSP observed the facility did not have fresh fruit present. DSP Manaloto could not provide copies of dated menus as served as requested by LPA Velazquez. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to clients.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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: PIERCE ADULT RESIDENTAL CARE HOME	FACILITY NUMBER: 306004296
	VISIT DATE: 04/06/2022

NARRATIVE

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First Aid kit was checked and found to be in order. The facility did have an updated First Aid guide.

LPA Velazquez along with DSP Manaloto toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for clients. Walkways around the home were not clear of hazards. LPA and DSP observed the following: a picnic table with cracked and jagged edges, a bottle of bleach, bottle of lighter fluid on the ground, pieces of wood, bicycle parts, rusty wheelbarrow, a chair with torn seat cushion, and an old fan. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit but LPA Velazquez provided DSP Manaloto with consultation on providing emergency responders with pertinent client information in the event of a 911 call.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 1. An exit interview was conducted with Direct Support Professional Gino Manaloto and a copy of this report along with the appeal rights< LIC 9102, and LIC 9098 were provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/06/2022 03:44 PM - It Cannot Be Edited

Created By: Patricia Velazquez On 04/06/2022 at 03:27 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: PIERCE ADULT RESIDENTAL CARE HOME	FACILITY NUMBER: 306004296
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80076(a)(19)

80076(a)(19) Food Services. (a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition..
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 4 stove top burners which poses/posed a potential health, safety or personal rights risk to persons in care. LPA and DSP observed the stove top fan was also inoperable.
	POC Due Date: 04/22/2022
	Plan of Correction
1 2 3 4	Licensee to repair or replace the inoperable stove top burners and the overhead fan and submit written proof to LPA by POC 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.

SUPERVISOR'S NAME:

Sheila Santos

LICENSING EVALUATOR NAME:

Patricia Velazquez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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