306004344-10-31-2024-22-AS-EKIM-DAKW2B-20241031165403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004344
Report Date: 10/31/2024
Date Signed: 10/31/2024 04:54:15 PM

Document Has Been Signed on 10/31/2024 04:54 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:	LADY MARIAN CARE HOME		FACILITY NUMBER:	306004344
ADMINISTRATOR/ DIRECTOR:	MAY NAVARRO WALLACE		FACILITY TYPE:	740
ADDRESS:	2459 N. ROBINHOOD PLACE		TELEPHONE:	(714) 202-5777
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	10/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:55 PM
MET WITH:	Assistant Administrator- Rustan Domingo		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 October 31, 2024, at 12:55pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Czari Martinez and Assistant Administrator (AA) Rustan Domingo.

The facility is licensed to operate for six (6) nonambulatory resident and have a hospice waiver for four (4) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, two staff bedrooms, three (3) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, gated swimming pool, and an attached two-car garage.

LPA Kim toured inside and outside of the physical plant with AA Domingo. There were no obstructions on the premises. Swimming pool is inaccessible by being surrounded by a fence and locked gate doors. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, and Resident Room 6. Bathrooms were found to be clean and operational. The water temperature measured at 116.7 degrees F to 118.0 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills are conducted monthly and last conducted on October 26, 2024.

Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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 4

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: LADY MARIAN CARE HOME	FACILITY NUMBER: 306004344
	VISIT DATE: 10/31/2024

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

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-710-6647) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has one (1) fire extinguisher that was charged and mounted in the kitchen. Liability Insurance is effective 9/5/2024 and expires on 9/5/2025.

LPA Kim conducted an audit of five (5) resident files (R1-R5), four (4) staff files (S1-S4), and medication and medication administration review. LPA Kim conducted two (2) staff interviews.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. A Technical Violation was issued at this visit.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Assistant Administrator Rustan Domingo.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/31/2024 04:54 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: LADY MARIAN CARE HOME	FACILITY NUMBER: 306004344
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of four staff members. LPA observed Staff#3 (S3) did not have any training hours done for 2024. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide the 2024 training hours for S3 to CCLD via email to edward.kim@dss.ca.gov by POC due date November 14, 2024.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed R1,R2, R3, R4, and R5 were all diagnosed with dementia. R1 R2, R4, and R5 are missing their current Physician's Report, and R1, R2, R3, and R5 are missing their current reappraisal. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide the updated Physician's Report for R1, R2, R4, and R5, and an updated Reappraisal for R1, R2, R3, and R5 to CCLD via email to edward.kim@dss.ca.gov by POC due date November 14, 2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4