306004758-6-12-2024-22-AS-KLYN-D65UP8-20240611154508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004758
Report Date: 06/11/2024
Date Signed: 06/12/2024 07:50:07 AM

Document Has Been Signed on 06/12/2024 07:50 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	A&B AT HOME HEALTH HOME CARE FACILITY RCFE		FACILITY NUMBER:	306004758
ADMINISTRATOR:	JOIEY WSAA J. ONG		FACILITY TYPE:	740
ADDRESS:	24116 JUANENO DRIVE		TELEPHONE:	(949) 870-6588
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	06/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	Maria Raninga and Joiey Ong		TIME COMPLETED:	04:05 PM

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) Kimberly Lyman conducted an unannounced visit to A & B At Home Health Care Facility RCFE. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, all of which may be bedridden. Facility has an approved hospice waiver for 4 residents and the home currently has 5 residents, with one on hospice. LPA Lyman along with Administrator Joiey Ong toured the facility at 12:56 PM. LPA toured the physical plant, checked food service, and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, 6 resident bathrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed five residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.6 and 111 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the elements including thermometer, and scissors. LPA observed a locked storage area for cleaning supplies under the kitchen sink and toxins secured in the garage. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating for residents. Exit gates are unlocked. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 11/22/2023. CONT ON LIC809-C DATED 06/11/2024

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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 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: A&B AT HOME HEALTH HOME CARE FACILITY RCFE	FACILITY NUMBER: 306004758
	VISIT DATE: 06/11/2024

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

Facility provides activities in the form of exercise, music and bible studies. At 1:30 PM, LPA reviewed five resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of annual training and criminal record clearance. At 2:15 PM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/12/2024 07:50 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A&B AT HOME HEALTH HOME CARE FACILITY RCFE	FACILITY NUMBER: 306004758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in five out of five persons which poses a potential health, safety or personal rights risk to persons in care. Five out of five residents with half bed rails do not have corresponding physician orders for said rails.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee to obtain written physician orders fro bed rails and forward proof to LPA by POC due date.

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/12/2024 07:50 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A&B AT HOME HEALTH HOME CARE FACILITY RCFE	FACILITY NUMBER: 306004758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. The last emergency drill was conducted on 11/22/2023 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/12/2024
	Plan of Correction
1 2 3 4	Licensee to conduct an emergency drill and forward proof to LPA by POC due date.

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4