306004719-10-28-2022-22-AS-ETAA-CKMU95-20221028152235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004719
Report Date: 10/28/2022
Date Signed: 10/28/2022 03:22:44 PM

Document Has Been Signed on 10/28/2022 03:22 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:	ST. SIMON HOME II		FACILITY NUMBER:	306004719
ADMINISTRATOR:	RON MARCHELLO		FACILITY TYPE:	740
ADDRESS:	4704 AVENIDA DE LAS FLORES		TELEPHONE:	(951) 545-2934
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 5	DATE:	10/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Sheryll Hernandez		TIME COMPLETED:	03:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Administrator was unable to make the inspection.

The facility is a single-level structure licensed for six non-ambulatory with a hospice waiver for two with total care. One may be bedridden. This facility offers Residential Care for the Elderly.

At about 2:20 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 3 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 5 resident rooms 1 of which is a shared room. The facility also had a staff room which is inaccessible to residents. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 108.5 degrees Fahrenheit. Facility offers a 2-car garage which is used for storage, freezer, and refrigerator. Kitchen was in good repair with sharps and cleaning supplies kept locked. LPA noticed drawer for knifes did not have a lock. Administrator was made aware of this issue and will purchase a lock for the knifes.

For the exterior portion, furniture was in good repair; and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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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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: ST. SIMON HOME II	FACILITY NUMBER: 306004719
	VISIT DATE: 10/28/2022

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LPA Tapia viewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility.

LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to 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.

For this visit, one deficiency was issued.

LPA Tapia conducted an exit interview with staff and copy of this report along with appeal rights were explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/28/2022 03:22 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: ST. SIMON HOME II	FACILITY NUMBER: 306004719
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

This requirement is not met as evidenced by: The following shall be stored inaccessible to residents with dementia. Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one knife drawer in the kitchen did not have a lock which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2022
	Plan of Correction
1 2 3 4	Administrator will purchase a lock for the knife drawer in the kitchen.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC809 (FAS) - (06/04)

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