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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004780
Report Date: 02/13/2024
Date Signed: 02/14/2024 09:24:44 AM


Document Has Been Signed on 02/14/2024 09:24 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:AMERIDGE RESIDENTIAL CAREFACILITY NUMBER:
306004780
ADMINISTRATOR:ANGELO BUENAVENTURAFACILITY TYPE:
740
ADDRESS:620 E. FERN DRIVETELEPHONE:
(714) 932-9276
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angelo Buenaventura- Administrator/LicenseeTIME COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct an annual visit. LPA was greeted and granted entry into the facility by Caregiver Nero Kaw and explained the reason for the visit. Administrator/Licensee Angelo Buenaventura arrived at the facility at 10:30 am.

The facility is licensed as a 4 bedroom 3 bathroom facility, 4 residents rooms and 1 resident bathroom and 1 staff bathroom. LPA Mendivil toured the facility with staff Nero at 9:10am. LPA Mendivil observed a fifth room, which contains a bed, dresser and personal affects of a staff member. LPA Mendivil observed all residents rooms to contain all required elements including: bed, dresser/closet space, lamp and chair. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 115.1 and 120.5 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. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 9:40am, . Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed emergency water supply on-site. LPA reviewed the emergency disaster plan during the visit. Administrator stated the last emergency drill conducted was prior to last CCLD visit in 2021. Facility provides activities in the form of music, coloring and puzzle activities. CONT ON LIC 809C DATED 02/13/2024
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AMERIDGE RESIDENTIAL CARE
FACILITY NUMBER: 306004780
VISIT DATE: 02/13/2024
NARRATIVE
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At 10:00am, LPA reviewed 6 resident files and 5 staff files. Resident files contained required documents including admission agreements. LPA observed the residents files in 6 out of 6 did not contain updated physician reports and resident appraisals. Staff files reviewed contained required documentation of health screen/TB, criminal record clearance. At 11 AM, LPA reviewed medication storage and administration. LPA observed Medication Administration Records to have medication signed off until 2/18/2024, based on Administrator the facility staff pre-pours medications for the week.

Facility is licensed for 6 non ambulatory residents and a hospice waiver for 2 residents. LPA observed facility to have 1 bedridden resident and 4 residents on hospice.

Based on the observations made during today's visit, the following violation is 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 OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/14/2024 09:24 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: AMERIDGE RESIDENTIAL CARE
FACILITY NUMBER: 306004780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87208(d)
(d) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f).

This requirement is not met as evidenced by: Licensee stated they did not submit Plan of Operations with bedridden plans as they did not obtain their license with bedridden approval.
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee agrees to submit updated Plan of Operations to LPA by POC due date
Type A
Section Cited
CCR
87465(h)(5)
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by: Facility had medications pre poured until 2/18/2024
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 out of 6 persons which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee will conduct an in service training to advise of regulation and provide 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 02/14/2024 09:24 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: AMERIDGE RESIDENTIAL CARE
FACILITY NUMBER: 306004780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(b)
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by: Licensee stated they have not had a drill since 2021.
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee agreed to conduct a drill and provide LPA proof of in service by POC due date.
Type A
Section Cited
CCR
87606(c)
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by: Facility does not have fire clearance for bedridden residents.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health and safety rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee agreed to submit for updated fire clearance and provide proof to LPA by POC 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 02/14/2024 09:24 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: AMERIDGE RESIDENTIAL CARE
FACILITY NUMBER: 306004780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by: Residents files did not contain updated LIC 602 Medical Assessment.

Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 persons in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee agreed to obtain updated LIC 602 or another updated medical form by POC due date.
Type A
Section Cited
CCR
87632(a)
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility.

This requirement is not met as evidenced by: Licensee did not request an updated waiver increase from CCLD prior to accepting residents.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee agreed to submit a request for increase of hospice waiver from 2 to 6. Licensee will submit to LPA Mendivil 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 02/14/2024 09:24 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: AMERIDGE RESIDENTIAL CARE
FACILITY NUMBER: 306004780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by: LPA Mendivil observed office/ staff lounge room utlized as a bedroom , as bedroom has a bed, dresser and personal affects of a staff member.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee agreed to remove bed and replace with sofa for staff to utilize as a breakroom and provide proof by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6