306004312-9-16-2022-22-AS-JCHO-CJBTYJ-20220916150849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004312
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:09:00 PM

Document Has Been Signed on 09/16/2022 03:09 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:	PRECIOUS HOME CARE II		FACILITY NUMBER:	306004312
ADMINISTRATOR:	GRACE RADFORD		FACILITY TYPE:	740
ADDRESS:	24531 VANESSA DRIVE		TELEPHONE:	(949) 215-3090
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Grace Radford		TIME COMPLETED:	03:23 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 09/16/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Precious Home Care II. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 12:38pm, LPA Cho was allowed entry by House Staff Gil Perez after completing the Coronavirus 2019 (COVID-19) screening procedure. Care Staffs Camencita Reyes, Vicente De Mesa, and Gilbert Tenorio were present at the facility. Administrator (Admin) Grace Radford arrived at the facility at 12:52pm. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) was within the size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for six. There are six residents living in the facility of which three are receiving hospice care. The Administrator's Certificate for Grace Radford expires on 01/28/24 and on 04/21/23 for Andy Radford. At 12:46pm, LPA Cho conducted a tour of the physical plant along with Admin Radford. The single story home consists of six resident bedrooms and four resident bathrooms. There is one staff bedroom. The facility also has a living room, family room, dining area, kitchen, laundry room, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. A camera was observed in Bedroom #1 above the dresser, and the camera was removed immediately. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 109.4 degrees Fahrenheit in the Bathroom #1, 105.6 degrees Fahrenheit in Bathroom #2, 107.4 degrees Fahrenheit in Bathroom #3, and 108.1 degrees Fahrenheit in Bathroom #4.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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 3

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: PRECIOUS HOME CARE II	FACILITY NUMBER: 306004312
	VISIT DATE: 09/16/2022

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
26
27
28
29
30
31
32

LPA Cho inspected the kitchen along with Admin Radford and Caregiver Carmencita Reyes. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds along with Admin. There is a small, elevated fountain in the yard. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gates were self-closing and self-latching. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components, and the facility had sufficient PPEs. Facility reviewed the infection control plan of the facility as well as Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides a smart phone upon request.

LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Grace Radford, and a copy of this report (including LIC809, LIC809C, LIC809D, and the appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/16/2022 03:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PRECIOUS HOME CARE II	FACILITY NUMBER: 306004312
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.2(a)(1)

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.2, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview of Administrator, the facility utilizes a camera in one out of six bedrooms and is not providing R1 a reasonable level of personal privacy which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	Licensee agrees the baby monitor camera will not be used in the bedroom of R1, and the camera was immediately removed during the visit.

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	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3