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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004791
Report Date:
09/10/2024
Date Signed:
09/10/2024 02:57:37 PM
Document Has Been Signed on
09/10/2024 02:57 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
LOS TIEMPOS SENIOR LIVING #3
FACILITY NUMBER:
306004791
ADMINISTRATOR:
FIGUEROA,LESLY
FACILITY TYPE:
740
ADDRESS:
10869 GOLDENEYE AVE
TELEPHONE:
(714) 928-7912
CITY:
FOUNTAIN VALLEY
STATE:
CA
ZIP CODE:
92708
CAPACITY:
6
CENSUS:
6
DATE:
09/10/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:10 AM
MET WITH:
Janeth Figueroa
TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joseph Alejandre and Samer Haddadin made an unannounced visit to conduct the required annual inspection. LPAs met with Licensee Janeth Figueroa and explained the reason for the visit. Facility is a one story home with 5 bedrooms, 3 bathrooms, living room, dining room, kitchen and an attached two car garage. Facility is licensed for 6 non-ambulatory residents and a hospice waiver for 4. LPA observed the see something, say something poster (PUB 475) is 8 1/2 by 11 inches. LPA observed the fireplace in the living room and the fireplace in the dining room are not screened. Licensee reported that the fireplaces are not in use. LPAs and the Licensee toured the facility. LPAs observed all resident rooms had the required furnishings and bed linens. All 3 bathrooms are clean and operational, grab bars are secure and non-slip mats in place. Hot water measured 108.0 to 109.8 degrees Fahrenheit. LPAs observed a clean supply of linens and towels in the hall closets. Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the living room and dining room are fully charged. LPAs observed the kitchen is clean and organized. The medication is kept locked in the closet. The kitchen stove lights unassisted. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPAs observed the lock on the drawer for the knives and sharp objects is inoperable. The garage is used for storage and kept locked. LPAs and the Licensee toured the backyard. No bodies of water observed. There is a table with an umbrella and chairs to sit outside. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPAs reviewed facility documents. There is no record of any emergency drills being conducted in 2024. LPAs reviewed 6 resident files and medications. LPAs observed the residents' medication is pre-poured and stored in plastic containers for tomorrow. LPAs observed Resident 3 (R3) does not have a current physician's report (LIC 602a). LPAs reviewed 3 staff files. 3 out of 3 staff files did not have verification for 20 hours of current annual training. All 3 staff have current CPR training. LPAs inspected the first aid kit. The first aid kit has all the required elements. LPA consulted with the Licensee regarding reporting requirements and safety requirements for RCFEs. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE:
09/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
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Document Has Been Signed on
09/10/2024 02:57 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
LOS TIEMPOS SENIOR LIVING #3
FACILITY NUMBER:
306004791
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fireplaces, LPAs observed the fireplace in the dining room and the fireplace in the living room are not screened which poses a potential health and safety risk to persons in care.
POC Due Date:
09/25/2024
Plan of Correction
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Licensee agrees to have install fireplace screens for both fireplaces. LIcensee to forward proof to LPA by POC due date.
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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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 members which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/10/2024
Plan of Correction
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4
Licensee agrees to have all 3 staff members trained to meet the regulatory requirements. Licensee to forward 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:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE:
09/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/10/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
09/10/2024 02:57 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
LOS TIEMPOS SENIOR LIVING #3
FACILITY NUMBER:
306004791
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(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:
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 residents' medication which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/17/2024
Plan of Correction
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Licensee agrees to keep residents medication in its original container until administered. Licensee to provide a signed stated certifying they have read and understand regulation 87465.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review the licensee did not comply with the section cited above in 1 out of 6 resident files, R3 did not have a current medication assessment, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/25/2024
Plan of Correction
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3
4
Licensee agrees to get a new updated medical assessment for R3 and to submit proof to LPA by the 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:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE:
09/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/10/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
09/10/2024 02:57 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
LOS TIEMPOS SENIOR LIVING #3
FACILITY NUMBER:
306004791
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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4
Based on record review, the licensee did not comply with the section cited above, there is no documentation that the facility conducted an emergency drill in 2024, which poses a potential health and safety risk to persons in care.
POC Due Date:
09/25/2024
Plan of Correction
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Licensee agrees to conduct an emergency disaster drill and to document it before the POC due date. Licensee agree to conduct emergency drills every quarter in compliance with the regulation above.
Type B
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above, LPA observed the drawer which stores the knives did not have a working lock which poses a potential health and safety or personal risk to persons in care.
POC Due Date:
09/17/2024
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:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE:
09/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/10/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5