306004780-1-30-2025-22-AS-SHAD-DDETET-20250130134029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004780
Report Date: 01/30/2025
Date Signed: 01/30/2025 01:40:40 PM

Document Has Been Signed on 01/30/2025 01:40 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:	AMERIDGE RESIDENTIAL CARE		FACILITY NUMBER:	306004780
ADMINISTRATOR/ DIRECTOR:	ANGELO BUENAVENTURA		FACILITY TYPE:	740
ADDRESS:	620 E. FERN DRIVE		TELEPHONE:	(714) 932-9276
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:30 AM
MET WITH:	Angelo Buenaventura		TIME VISIT/ INSPECTION COMPLETED:	01:55 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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Angelo Buenaventura and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 8:00AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 3-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 5 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114 and 116 degrees F in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the hallway, after corrections. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:30AM, LPA reviewed 5 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 5 residents. Facility does not handle resident money. CONTINUED

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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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Document Has Been Signed on 01/30/2025 01:40 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: AMERIDGE RESIDENTIAL CARE	FACILITY NUMBER: 306004780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure toxins, including bleach, were inaccessible in the non-lockable garage, which poses an immediate safety risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	During the inspection, the licensee secured these items and LPA confirmed. Licensee stated they will retrain staff on securing dangerous items and submit proof to LPA by 02/06/25.

Type A

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and admission, Resident #1 (R1) had a full bedrail on their bed but is not on hospice, which poses an immediate personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	During the inspection, the licensee removed the full bedrail and LPA confirmed. Licensee stated they will conduct staff training on bedrails and submit proof to LPA by 02/06/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2025 01:40 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: AMERIDGE RESIDENTIAL CARE	FACILITY NUMBER: 306004780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87633(a)(1)

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on admission and documents, the facility has a hospice waiver for 2 but currently has 3 residents on hospice, which poses an immediate health risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee stated they will submit a hospice waiver increase request 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.

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2025 01:40 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: AMERIDGE RESIDENTIAL CARE	FACILITY NUMBER: 306004780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the facility does not have an Infection Control Plan, which poses a potential health risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan to LPA by POC due date.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) 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 observation, the facility's fire extinguishers were purchased in 2022 and have not been inspected since, which poses a potential safety risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will purchase new fire extinguishers or have the fire extinguishers inspected and submit proof to LPA by POC due 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.

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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: AMERIDGE RESIDENTIAL CARE	FACILITY NUMBER: 306004780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Guardian records and admission, Staff #1 (S1) Mileah L Evangelista has been working at the facility for over a year and is background cleared, but is not associated to the facility, which poses a potential safety risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will associate S1 to the facility and submit proof to LPA by POC due date.

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure 2 out of 2 staff had documented medication training, which poses a potential health risk to persons in risk.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will review PIN 23-16-ASC, complete the medication training for staff, and submit proof to LPA by POC due 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.

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 01/30/2025 01:40 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: AMERIDGE RESIDENTIAL CARE	FACILITY NUMBER: 306004780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 documents and admission, the licensee has not been conducting emergency disaster drills, which poses a potential safety risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will conduct an emergency disaster drill immediately, submit proof to LPA by POC due date, and will conduct emergency disaster drills quarterly moving forward.

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.

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

Page: 6 of 7

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: AMERIDGE RESIDENTIAL CARE	FACILITY NUMBER: 306004780
	VISIT DATE: 01/30/2025

NARRATIVE

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During the inspection, LPA and AD observed the following: based on documents, the facility does not have an Infection Control Plan; based on observation, the facility's fire extinguishers were purchased in 2022 and have not been inspected since; based on observation, the licensee did not ensure toxins, including bleach, were inaccessible in the non-lockable garage; based on Guardian records and admission, Staff #1 (S1) Mileah L Evangelista has been working at the facility for over a year and is background cleared, but is not associated to the facility; based on documents, the licensee did not ensure 2 out of 2 staff had documented medication training; based on documents and admission, the licensee has not been conducting emergency disaster drills; based on observation and admission, Resident #1 (R1) had a full bedrail on their bed but is not on hospice; and based on admission and documents, the facility has a hospice waiver for 2 but currently has 3 residents on hospice.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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