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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004545
Report Date: 06/07/2024
Date Signed: 06/07/2024 05:00:18 PM


Document Has Been Signed on 06/07/2024 05:00 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:ASTORIA RETIREMENT AT DOVER SHORESFACILITY NUMBER:
306004545
ADMINISTRATOR:OANA ABRUDANFACILITY TYPE:
740
ADDRESS:1412 SANTIAGO DRIVETELEPHONE:
(714) 306-2253
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY:6CENSUS: 6DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Oana Abrudan, Administrator (via telephone)TIME COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after stating the purpose of the visit. Administrator Oana Abrudan was notified of the visit via telephone and arrived later of the conclusion..

During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one-story home. Facility has six private rooms for residents along with one staff room, as well as two shared bathrooms and one half bathroom in addition to the common living areas. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. The backyard has a shaded area and the exterior route of egress is free of clutter and obstructions. The pool is observed to be secure. There are currently six residents admitted to the facility including two residents currently receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher present is observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed six resident files and three staff files.

Based on the observations made during today’s inspection, one type A deficiency and two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Two Technical Violation Advisory Notes were also provided to the licensee based on consultation provided during the visit. An exit interview was conducted, and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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 06/07/2024 05:00 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: ASTORIA RETIREMENT AT DOVER SHORES
FACILITY NUMBER: 306004545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, the licensee did not comply with the section cited above as one resident is documented to be bedridden, however the current fire clearance on file does not include the provision for bedridden individuals. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2024
Plan of Correction
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Licensee will coordinate with the Department of Social Services and the local fire authority to initiate the process of obtaining a fire clearance for at least one bedridden resident.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 06/07/2024 05:00 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: ASTORIA RETIREMENT AT DOVER SHORES
FACILITY NUMBER: 306004545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(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 and records review, the licensee did not comply with the section cited above as one resident not currently enrolled to receive hospice care was observed to have a bed equipped with full-length rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2024
Plan of Correction
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Licensee will obtain an appropriate order for half-rails and replace the currently equipped full rails. Documentation to be provided to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the visit, the licensee did not comply with the section cited above as no signs indicating a resident was currently using oxygen were on display which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2024
Plan of Correction
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Licensee will display the appropriate signage whenever oxygen is in use by one or more residents.
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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