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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004532
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:31:21 PM

Document Has Been Signed on 03/30/2022 03:31 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:ASSISTED SENIOR HOMEFACILITY NUMBER:
306004532
ADMINISTRATOR:Z. GLOUNERFACILITY TYPE:
740
ADDRESS:24741 PRISCILLATELEPHONE:
(949) 248-9415
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY: 6CENSUS: 5DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator/Caregiver TIME COMPLETED:
01:43 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to Assisted Senior Home. The purpose of today’s visit was to conduct the required 1 year visit. LPAs were allowed entry into the home and met with Caregiver Norma Hernandez. Facility is licensed for 6 non-ambulatory residents. The home currently has five residents with no residents on hospice. Administrator has an administrator certificate expiring on 01/07/2023.

At 11:05 AM, LPAs toured the facility with Administrator and Caregiver Norma Hernandez. Facility has 5 residents in care during today's visit. LPAs observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. During the tour of the kitchen at 11:10 AM, LPAs observed unsecured pre-poured prescription medication. All resident rooms had the required elements. At 11:15 AM, LPAs observed Resident 1 (R1) has rails extending the whole length of the bed. Facility screens all visitors to the facility and LPAs observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet/ questionnaire. Facility takes resident and staff temperatures daily and documents. LPAs observed an ample supply of emergency food and water. LPAs observed the shaded outside visitation area. Exit gates are self latching and unlocked. LPAs observed the locked medication area. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPAs reviewed all resident files during the visit and all files have updated emergency information. Upon review of associated staff, LPAs observed S1 is not associated to the facility. All residents and staff are vaccinated for Covid-19.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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Document Has Been Signed on 03/30/2022 03:31 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/30/2022 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ASSISTED SENIOR HOME
FACILITY NUMBER: 306004532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one staff which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Licensee to associate Staff 1 and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87608(a)(5)(B)
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 1 residents. LPAs observed R1 has rails extending the whole length of the bed. This poses an immediate health and safety risk to persons in care. (photos)
POC Due Date: 03/31/2022
Plan of Correction
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Licensee to remove rails and forward proof to LPA by POC due date. Licensee removed rails during visit.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/30/2022 03:31 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/30/2022 at 12:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ASSISTED SENIOR HOME
FACILITY NUMBER: 306004532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPAs observed pre-poured medication in an unlocked kitchen cabinet which poses an immediate health, safety risk to persons in care. (photos)
POC Due Date: 03/31/2022
Plan of Correction
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Licensee to secure medications and forward proof 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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
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