306004839-9-20-2024-22-AS-LMAZ-D9ATH4-20240920144407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:45:11 PM

Document Has Been Signed on 09/20/2024 02:45 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:	FULLERTON VILLA		FACILITY NUMBER:	306004839
ADMINISTRATOR:	JAE WAN RIM		FACILITY TYPE:	740
ADDRESS:	2441 W. ORANGETHORPE AVE.		TELEPHONE:	(714) 992-5380
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	197	CENSUS: 167	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jae Wan Rim		TIME COMPLETED:	03:00 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) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year inspection. LPA met with Administrator Jae Wan Rim. LPA confirmed Administrator has a current Administrator Certificate which expires on 05/15/2026 The facility is operating within capacity limitations. Facility currently has 167 residents in care of which six residents are under Hospice care. Community is mostly Korean speaking residents. LPA observed residents walking around socializing, or relaxing in their respective rooms. In-House Doctor was present seeing residents during today's visit. Residents were observed clean, content and well taken care of. LPA observed the facility to be clean and in good repair. LPA observed new flooring on first floor is being installed. Facility provided notice to CCL prior to start of installation. The facility is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Patio has a covered area with seating for residents and visitors. Hygiene items were observed to be readily available for residents in care. Hot water was found to be within regulatory requirements. Grab bars were found available in restrooms used by residents. As this is a multi-level licensed structure, a signal system was found in place, tested and functional. Annual Fire Inspection reports and Fire Prevention Services documentation was available for review. Records of Maintenance and Emergency Drills were available for review, last being 07/04/2024. Sprinkler system was inspected and documentation was reviewed. LPA, along with AD Rim toured and inspected the kitchen, reviewed lunch service and reviewed monthly dietician's inspection reports. Last dietician's report and sanitation survey form was dated 09/06/2024. Dietician provided in-service training in area of menu availability for Korean residents was observed. LPA observed menu posted in English and Korean. LPA observed a one week supply of nonperishable foods and two days of perishable foods. Pesticides and other toxins are stored away from food areas of the kitchen. Sharp items are also kept inaccessible from residents. LPA also observed adequate Care and Supervision for the number of residents in care. (cont...LIC809C)

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FULLERTON VILLA	FACILITY NUMBER: 306004839
	VISIT DATE: 09/20/2024

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Medications are centrally stored and inaccessible to residents in care. LPA observed medication is pre-poured for 3 days. LPA observed resident centered activities posted. LPA conducted interviews with residents and staff. LPA reviewed 16 resident files and 5 staff files

Based on observations made during today's visit, deficiency is being cited per Title 22. An exit interview was conducted with Administrator and a copy of this report (LIC809, LIC809D and Appeals Right) was sent to email on file.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2024 02:45 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: FULLERTON VILLA	FACILITY NUMBER: 306004839
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care. 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
1 2 3 4	Based on observation, interview and record reviews, the licensee did not comply with the section cited above in that medication is being pre-poured from original container more than 24 hours in advance (3 days) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	Facility to immediately stop pre-pouring medication. Administrator has agreed to self certify understanding of regulation and provide proof of correction by 09/23/2024

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: Lourdes Montoya	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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