306004407-3-28-2022-22-AS-PVEZ-CCXQTL-20220328122720

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004407
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:27:26 PM

Document Has Been Signed on 03/28/2022 12:27 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:	ROSSMOOR SUNSHINE VILLA-FOSTER		FACILITY NUMBER:	306004407
ADMINISTRATOR:	RICARDO BANOS		FACILITY TYPE:	740
ADDRESS:	12521 FOSTER ROAD		TELEPHONE:	(562) 572-9931
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	6	CENSUS: 5	DATE:	03/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	Flormine Resurreccion - Assistant Administrator		TIME COMPLETED:	12:40 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 Rossmoor Sunshine Villa-Foster. 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 Assistant Administrator (AA) Flormine Resurreccion. Caregivers Estelita Abella and Virginia Maaghup were also present. The facility is licensed for 6 non-ambulatory residents of which 1 may be bedridden. The facility has a Hospice waiver for 4 residents. There are currently 4 residents living in the facility but a 5th resident was being admitted during the visit. The last emergency disaster drill was conducted on February 6, 2022. LPA Velazquez observed the Complaint poster was not the correct size pursuant to regulation and advised AA to obtain the Complaint poster in the correct size of 20" x 26." At 11:00 AM LPA Velazquez conducted a tour of the physical plant along with AA Resurreccion. The 1 story home consists of 5 resident bedrooms with 4 bathrooms. There is 1 staff bedroom. The facility also has a living room, family room, dining room, and kitchen. The 4 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails in the resident bedrooms. AA Resurreccion indicated there were written physician orders for the bed rails present in the resident files. Resident bathrooms were checked. Resident 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 tested the hot water temperature in the resident bathrooms and the temperature measured at 109.4 degrees Fahrenheit in the first bathroom, at 109.5 degrees Fahrenheit in the second bathroom, at 112.4 degrees in the left sink and at 112.4 in the right sink of the third bathroom, and at 114.9 degrees Fahrenheit in the fourth bathroom which AA Resurreccion verified.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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: ROSSMOOR SUNSHINE VILLA-FOSTER	FACILITY NUMBER: 306004407
	VISIT DATE: 03/28/2022

NARRATIVE

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LPA Velazquez inspected the kitchen along with AA Resurreccion. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. AA Resurreccion informed LPA Velazquez that the dishwasher was inoperable. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition. LPA Velazquez observed the presence of cameras in the common areas of the facility. First Aid kit was checked and found to be in order. The facility did have a First Aid manual dated 2011 and LPA Velazquez advised AA Resurreccion to obtain an updated First Aid manual.

LPA Velazquez along with AA Resurreccion toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gate was operational. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed AA Resurreccion to ensure a written physician's order indicating the need for the bed rails is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports which LPA reviewed with AA Resurreccion.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Assistant Administrator Maria Tavarez and a copy of this report along with the appeal rights, and a copy of the LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/28/2022 12:27 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: ROSSMOOR SUNSHINE VILLA-FOSTER	FACILITY NUMBER: 306004407
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(32)

87555(b)(32) General Food Service Requirements. The following food service requirements shall apply: Equipment or appropriate size and type shall be provided for the storage, preparartion, and service of food and for sanitizing utensila and tableware, and shall be well maintained.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 dishawasher which poses a potential health, safety or personal rights risk to persons in care. Assistant Administrator Flormine Resurreccion informed LPA Velazquez that the dishwasher in the kitchen was inoperable.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Licensee to repair or replace the dishwasher 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	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC809 (FAS) - (06/04)

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