306004478-8-2-2024-22-AS-MTEA-D7RPSZ-20240802113511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004478
Report Date: 08/02/2024
Date Signed: 08/02/2024 11:35:30 AM

Document Has Been Signed on 08/02/2024 11:35 AM - 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:	PRINCEVILLE - COLLEGE PARK		FACILITY NUMBER:	306004478
ADMINISTRATOR:	MYRIAM OLIVER		FACILITY TYPE:	740
ADDRESS:	3601 OLEANDER STREET		TELEPHONE:	(562) 296-8800
CITY:	SEAL BEACH	STATE: CA	ZIP CODE:	90740
CAPACITY:	6	CENSUS: 3	DATE:	08/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Karl Padua		TIME COMPLETED:	11:50 AM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:00 AM, LPA Tea was greeted and granted entry into the facility by caregiver, Jose Vasquez Jr. and explained the reason for the visit. The Administrator (AD), Myriam Oliver is currently off today, the backup Administrator (AD) Karl Padua from their sister facility Princeville - Bolsa Chica arrived shortly after to assist during the visit. The facility is licensed for 6 non-ambulatory residents, with a hospice waiver for four. Currently there are three residents, of which one is on hospice during today's visit.

Around 8:21 AM, LPA Tea reviewed three resident files and one staff file. Resident files and staff file contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted in June 07, 2024. AD Oliver current certificate expires on June 10, 2026, but due to the department’s back log in processing administrator certificates she has yet to physically receive her administrator certificate.

LPA Tea along with the AD Padua toured the facility at 9:03 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 5 resident bedrooms, one staff room, which is kept locked, 2 full bathrooms and 1 half bathroom, living room, dining room, kitchen and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 113.5 F degrees and 118.2 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

Annual continuation on LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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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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: PRINCEVILLE - COLLEGE PARK	FACILITY NUMBER: 306004478
	VISIT DATE: 08/02/2024

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LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink. Fire extinguisher was fully charged in the kitchen. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There is a water fountain and flowers surrounding the seating area. There are two exit gates that are self-latching and operational on both sides of the house. LPA observed emergency water supply and other supplies in the garage. There is emergency food stored in the pantry in the kitchen. Facility provides activities based on their personal choice, residents sometimes work on puzzles with the staff, and they play bingo. At the time of the visit, LPA observed residents enjoying breakfast together in the dining room and lounging in the living room watching television.

At 9:26 AM LPA reviewed medication storage and administration. Medications are stored in a locked closet by the front entryway. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Karl Padua and a copy of this report LIC809, along with the 809-C, LIC858, LIC859 and LIC9102 were read and provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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