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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004628
Report Date: 10/17/2022
Date Signed: 10/17/2022 04:24:05 PM


Document Has Been Signed on 10/17/2022 04:24 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:CASA DOCTORA IIIFACILITY NUMBER:
306004628
ADMINISTRATOR:KRAMER, PAUL/ESTELAFACILITY TYPE:
740
ADDRESS:25492 MAXIMUS STREETTELEPHONE:
(949) 380-7379
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Facility Administrator- Estela KramerTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 4 staff were on duty, who contacted facility administrator (AD) Estela Kramer about visit. As of 10/17/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the facility entrance and by the staff desk located by the kitchen. LPA De Perio observed the Administrator's Certificate for Paul Kramer which expires on 10/27/23. AD E. Kramer submitted renewal for certificate on 7/12/22 and provided proof of payment and documentation to LPA De Perio stating that renewal fee was received on 8/2/22. Pending renewed certificate.

LPA De Perio toured the interior and exterior portions of the facility with AD Kramer. The facility is a single level structure and is licensed for 4 non-ambulatory residents of which 2 may be bedridden and 6 may be on hospice. For this visit, there are a total of 6 residents in care, of which 1 is on hospice and 0 bedridden. There are a total of 7 bedrooms, of which 5 are private resident rooms, 1 shared resident room and 1 for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms of which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 109.9 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Facility had a fire extinguisher located in the kitchen and is mounted and charged.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CASA DOCTORA III
FACILITY NUMBER: 306004628
VISIT DATE: 10/17/2022
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LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the kitchen pantry. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the facility hallway. Toxins in the bathroom were also observed to be locked and inaccessible to residents.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which was self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Kramer. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Kramer to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Kramer.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA De Perio advised AD Kramer to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Kramer and a copy of this report, LIC809D, Appeal Rights copies of the regulations discussed were provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/17/2022 04:24 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CASA DOCTORA III
FACILITY NUMBER: 306004628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms, and other items which could post a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee failed to lock disinfectants, cleaning solutions, poisons, and other items which could post a danger. LPA observed cleaning supplies and disinfectants stored in an unlocked cabinet located under the kitchen sink. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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Licensee will lock and ensure that all toxins and disinfectants are inaccessible to residents in care. Licensee will comply with the POC on or by 10/31/2022 and submit proof to assigned LPA and Community Care Licensing.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care

(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, interview and file review, the facility failed to keep the centrally stored medication in a safe and locked place that is not accessible to residents in care, other than employees responsible for the supervision of centrally stored medication. LPA De Perio observed an unlocked mini refrigerator under the kitchen island that had bottles of liquid medications and pills. LPA De Perio also observed an unlocked medication cabinet located by the staff desk. AD locked refrigerator and cabinet. Threat reduced. This poses an immediate threat on the health and safety of the residents in care.
POC Due Date: 10/31/2022
Plan of Correction
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Licensee will lock and ensure that all medications are locked and inaccessible to residents in care. Licensee will comply with the POC on or by 10/31/2022 and submit proof to assigned LPA and Community Care Licensing.

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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4