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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004761
Report Date: 12/07/2024
Date Signed: 12/07/2024 04:07:32 PM

Document Has Been Signed on 12/07/2024 04:07 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
Lookup Error,
, CA
FACILITY NAME:CAMBRIDGE COURTFACILITY NUMBER:
306004761
ADMINISTRATOR/
DIRECTOR:		LAUREN CHONFACILITY TYPE:
740
ADDRESS:1621 COMMONWEALTH AVENUE, EASTTELEPHONE:
(714) 992-1750
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 99CENSUS: 75DATE:
12/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Supervisor Lupe JaimeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a required annual inspection on 12/07/2024. LPA met with Lupe Jaime (House Keeping/Purchasing Supervisor) and discussed the purpose of today’s visit. The facility is licensed for ninety-nine (99) non-ambulatory residents, age 60 and over. The facility has an approved hospice waiver for nine (9) residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants and cleaning solutions that could pose a danger if readily available to residents, were observed to be accessible in resident room#118. Staff removed disinfectant and cleaning solutions after LPA Ramirez made observation. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected seven (7) resident rooms. All resident bedrooms contained required furniture, linens, and lighting. Water temperatures in grooming and bathing areas were measured to be above 120 degrees F. 1st floor communal bathroom sink water temperature was measured to be 129.4 degrees F, during inspection. Resident room# 112, bathroom sink water temperature was measured to be 122.7 degrees F during inspection. Resident room# 213, bathroom sink water temperature was measured to be 124.0 degrees F during inspection. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed emergency call cords to be operational. LPA Ramirez observed video surveillance in common areas of the facility.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets.

See 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2024
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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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: CAMBRIDGE COURT
FACILITY NUMBER: 306004761
VISIT DATE: 12/07/2024
NARRATIVE
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Planned Activities: LPA Ramirez observed an activities calendar for December of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drill was conducted on 11/06/24 and 10/03/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility.



Operational Requirements: The facility is licensed for ninety-nine (99) non-ambulatory residents, age 60 and over. The facility has an approved hospice waiver for nine (9) residents. LPA Ramirez reviewed facility liability insurance and auto registration for one (1) facility vehicle.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez did not observe documented required initial training for S1 and S2. LPA did not observe completed 20 required annual training hours for S1, S2, and S3. S1 completed 9 out of 20 required annual training hours. S2 completed 10 out of 20 required annual training hours. S3 completed 9 out of 20 required annual training hours.

Staffing: Administrator Certificate for Lauren Chon and it expires 10/09/2025.



Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Four (4) deficiencies were observed and cited during inspection. Exit interview was conducted and a copy of this report, 9099-D, and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/07/2024 04:07 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/07/2024 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: CAMBRIDGE COURT
FACILITY NUMBER: 306004761

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, water temperatures checked in various grooming areas of the facility measured above 120 degree F, the licensee did not comply with the section cited above in 75 out of 75 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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2
3
4
*Staff adjusted facility water broiler. This clears 24hr correction*
Licensee will re-train staff on this regulation. Proof of re-training must be received by 12/13/2024, via email to LPA Ramirez.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose 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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4
Based on observation, disinfectants and cleaning solutions were found accessible in resident bathroom, the licensee did not comply with the section cited above in 1 out of 75 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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2
3
4
*Staff removed disinfectants and cleaning solutions from resident bathroom. This clears 24HR correction.*
Licensee will re-train staff on this regulation. Proof of re-training must be received by 12/13/2024, via email to LPA Ramirez.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/07/2024 04:07 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/07/2024 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: CAMBRIDGE COURT
FACILITY NUMBER: 306004761

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, S1,S2 and S3 did not complete required 20 annual training hours, the licensee did not comply with the section cited above in 3 out of 4 personnel records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Licensee will re-train staff on this regulation and send proof of re-training by 12/13/24 to LPA Ramirez via email.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/07/2024 04:07 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/07/2024 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: CAMBRIDGE COURT
FACILITY NUMBER: 306004761

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(1)(A)
87412 Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (1) The following staff training and orientation shall be documented: (A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter in one or more of the content areas as specified in Section 87411(c)(2).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, S1 and S2 personnel records did not document initial training within four weeks of employment,the licensee did not comply with the section cited above in 2 out of 4 staff records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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2
3
4
Licensee will re-train staff on this regulation and send proof of re-training by 12/13/24 to LPA Ramirez via email.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2024


LIC809 (FAS) - (06/04)
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