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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004454
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:30:37 PM

Document Has Been Signed on 11/18/2024 12:30 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:NS CAREFACILITY NUMBER:
306004454
ADMINISTRATOR/
DIRECTOR:		NOVAC SOFRONIFACILITY TYPE:
740
ADDRESS:10431 AVENIDA CINCO DE MAYOTELEPHONE:
(714) 599-3531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Novac Sofroni, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by Staff #1 at 8:15 AM. During today’s visit, LPAs met with Novac Sofroni, Administrator (AD).

The facility is a two-story, ten bedroom, nine bathroom residential building with an approved fire clearance of six non-ambulatory residents of which six may be bedridden and two are approved for hospice. The facility currently has a census of six residents in care of which two residents are on hospice.

During today’s visit, LPAs toured the facility and inspected the physical plant, including but not limited to testing all smoke and carbon monoxide detectors, testing hot water temperatures in four of four resident bathrooms, and testing auditory devices on all exits. The hot water temperatures measured between 105.6 and 118.5 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. LPAs observed the PUB 475 "See Something, Say Something" poster was not 20" X 26."

The fire extinguisher is charged and was serviced on November 2023. AD purchased new fire extinguishers during our visit. The facility’s last fire drill was conducted on June 1, 2024. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPAs observed medication storage and reviewed the centrally stored medications. Per review of medications it is not clear if medications are being given as prescribed.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPAs interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPAs confirmed that administrator has a current administrator certificate which expires on June 26, 2025.
(Continued on LIC 809-C)
Alisa OrtizTELEPHONE: (714) 287-4084
RoseMarie RuppertTELEPHONE: 714-703-2840
DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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Document Has Been Signed on 11/18/2024 12:30 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: NS CARE
FACILITY NUMBER: 306004454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs file review and interviews, the licensee did not comply with the section cited above in four of four staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator (AD) will have four of four staff do online CPR/ First Aid training within 24 hours and email LPA Ruppert with course completion certificates.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa OrtizTELEPHONE: (714) 287-4084
RoseMarie RuppertTELEPHONE: 714-703-2840

DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 12:30 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: NS CARE
FACILITY NUMBER: 306004454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs file review and interview the licensee did not comply with the section cited above in four of four staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Administrator (AD) will complete LIC 503 Health Screening and show documentation that four of four staff are TB cleared. AD will email LIC 503s by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa OrtizTELEPHONE: (714) 287-4084
RoseMarie RuppertTELEPHONE: 714-703-2840

DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 12:30 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: NS CARE
FACILITY NUMBER: 306004454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, observations and interview, the licensee did not comply with the section cited above in six of six residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Administrator (AD) will create and update Medication Administration Records (MAR) for six of six residents and submit to LPA Ruppert via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa OrtizTELEPHONE: (714) 287-4084
RoseMarie RuppertTELEPHONE: 714-703-2840

DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024

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: NS CARE
FACILITY NUMBER: 306004454
VISIT DATE: 11/18/2024
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(Continued from LIC 809)

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Novac Sofroni, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC 9102-TVs and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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