306005150-10-9-2023-22-AS-SHAD-CWFVJ9-20231009162823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005150
Report Date: 10/09/2023
Date Signed: 10/09/2023 04:28:36 PM

Document Has Been Signed on 10/09/2023 04:28 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:	NOUMEA CARE HOME		FACILITY NUMBER:	306005150
ADMINISTRATOR:	CONSOLACION BURGOS		FACILITY TYPE:	735
ADDRESS:	729 S WASCO RD		TELEPHONE:	(714) 891-1233
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 6		CENSUS: 5	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Fortune Saturno, Melba Santos		TIME COMPLETED:	04:40 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 Staff #1 (S1) Fortune Saturno and discussed the purpose of the inspection. Administrator (AD) Melba Santos arrived during the inspection. LPA reviewed Infection Control requirements. At about 12:45PM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client 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 being used for storage. There is a back yard with a patio cover for the clients. LPA observed 2 staff and 2 clients present at the facility. Client Bedrooms: the 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: LPA inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 114 degrees F in the East client bathroom and 111 in the West client bathroom. Linens & Hygiene Supplies: 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, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked under the kitchen sink and in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed the facility’s licensing fees with AD. At about 1:45PM, LPA reviewed 5 client files and 5 staff files, interviewed 2 clients and 2 staff, inspected medications for 5 clients, and inspected client money and ledgers for 5 clients. CONTINUED.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 10/09/2023 04:28 PM - It Cannot Be Edited

Created By: Sean Haddad On 10/09/2023 at 04:13 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NOUMEA CARE HOME	FACILITY NUMBER: 306005150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80010(b)

Limitations on Capacity and Ambulatory Status

(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, 1 out of 5 clients is non-ambulatory but the facility does not have a non-ambulatory fire clearance, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Licensee stated they will request a new fire clearance for non-ambulatory clients 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.

SUPERVISOR'S NAME:

Armando J Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/09/2023 04:28 PM - It Cannot Be Edited

Created By: Sean Haddad On 10/09/2023 at 04:13 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NOUMEA CARE HOME	FACILITY NUMBER: 306005150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
1 2 3 4	Based on observation, the licensee did not ensure a saw, hammer, screwdrivers, and paint sprays were inaccessible to clients in the non-lockable file cabinet in the backyard, which poses a potential safety risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	During the inspection, the licensee secured these items and LPA confirmed. The licensee stated they will retrain staff on securing dangerous items and submit proof 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.

SUPERVISOR'S NAME:

Armando J Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: NOUMEA CARE HOME	FACILITY NUMBER: 306005150
	VISIT DATE: 10/09/2023

NARRATIVE

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During the inspection, LPA and S1 observed the following. A saw, hammer, screwdrivers, and paint sprays were accessible to clients in the non-lockable file cabinet in the backyard. This is a Level 2 facility and facility staff stated the clients do not have histories of self-harm or aggression. Per Physician’s Reports dated 07/31/23, 05/09/22, 06/28/21, 05/03/21, and an incomplete Physician’s Report from 2019, Resident #1 (R1) is non-ambulatory. However, the facility does not have a fire clearance for non-ambulatory clients.

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. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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