<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004598
Report Date: 07/12/2024
Date Signed: 07/15/2024 08:41:07 AM


Document Has Been Signed on 07/15/2024 08:41 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
Lookup Error,
, CA



FACILITY NAME:DELIGHTFUL LIVINGFACILITY NUMBER:
306004598
ADMINISTRATOR:REBEKAH BUBOIFACILITY TYPE:
740
ADDRESS:26811 CARMENITA LANETELEPHONE:
(714) 600-5845
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Caregiver Francisco BautistaTIME COMPLETED:
10:40 AM
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) Iby Strong conducted an unannounced Required Annual Inspection. The
facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the
purpose of the visit with Caregiver Francisco Bautista. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory and one may be bedridden.

LPA toured the interior and exterior of the facility and inspected each room. This facility is a two story home, second floor is staff only. The facility was sanitary. LPA observed multiple uncovered electrical outlets in the living room space and unfinished walls. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were cleaning supplies accessible to residents under the kitchen sink and bathroom sinks. Knives were easily accessible in kitchen drawer. Medications were labeled, as required, but not stored in locked area, making them accessible to residents.

No pool or body of water present. Water temperature was measured at 118 degrees F. Per Francisco, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit was complete. No fire drills have been conducted this quarter. No oxygen in-use sign was not present while there is a resident on oxygen.

Resident 1's (R1) LIC 602 physician report had not been updated since 2018 and has a diagnosis of a major neurocognitive disorder. Resident 2 (R2) did not have an order for a full bed rail and was not on hospice. Staff records reviewed contained required documentation.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 07/15/2024 08:41 AM - 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
Lookup Error,
, CA


FACILITY NAME: DELIGHTFUL LIVING
FACILITY NUMBER: 306004598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations there are multple exposed electrical wire outlets without covers and, unfinished wall trim, the licensee did not comply with the section cited above in six of six residents which poses a potential safety risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee agrees to complete such work by POC date.
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
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in one out of six residents[R1] which poses safety and personal rights risk to persons in care.
POC Due Date: 07/14/2024
Plan of Correction
1
2
3
4
Licensee agrees to remove ful bed rail and replace with half rail 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.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 07/15/2024 08:41 AM - 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
Lookup Error,
, CA


FACILITY NAME: DELIGHTFUL LIVING
FACILITY NUMBER: 306004598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in five out of five residents in care which poses safety risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee agrees to post sign by POC date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in one out of four residents with dementia which poses posed a potential health risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee agrees to collect an updated LIC602 for resident 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.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 07/15/2024 08:41 AM - 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
Lookup Error,
, CA


FACILITY NAME: DELIGHTFUL LIVING
FACILITY NUMBER: 306004598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in all residents in care, which posed a potential safety risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee removed all items and placed them in locked areas. POC cleared.
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in all residnets in care which posed a potential safety risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee removed all items and placed them in locked areas. POC cleared.
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: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: DELIGHTFUL LIVING
FACILITY NUMBER: 306004598
VISIT DATE: 07/12/2024
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
26
27
28
29
30
31
32
Multiple deficiencies were issues on today's date and one technical violation. An exit interview was conducted with Caregiver, to whom a copy of this report, LIC809 D (x3), LIC9102 and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5