306005166-8-12-2024-22-AS-RMAZ-D83RPC-20240812131143

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005166
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:11:50 PM

Document Has Been Signed on 08/12/2024 01:11 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:	DELIGHTFUL LIVING TOO		FACILITY NUMBER:	306005166
ADMINISTRATOR:	BUBOI, REBEKAH		FACILITY TYPE:	740
ADDRESS:	24971 CAMBERWELL STREET		TELEPHONE:	(714) 600-5845
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Rebekah Buboi		TIME COMPLETED:	01:30 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 (LPAs) Ruth Martinez and Samer Haddadin are conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by caregiver and LPA explained the nature of the visit. Rebekah Buboi, Administrator arrived shortly after and met with LPAs. There are five residents at the facility and there is one resident receiving hospice services currently. LPAs began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage a refrigerator and a freezer located in the garage. LPA Martinez observe a fire extinguisher mounted on the wall of the kitchen with service date of 4/26/23. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in dining room. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 113.1 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored and locked in a storage cabinet located in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their Continued on LIC809-D

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 08/12/2024 01:11 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: DELIGHTFUL LIVING TOO	FACILITY NUMBER: 306005166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

Fire Clearance

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations LPA Martinez observe fire extinguisher in kitchen was last service date of 4/26/23, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Licensee to immediately called to have the facility fire extinguisher serviced. Service was scheduled for 8/15/24. Licensee was reminded that fire extinguisher is to be serviced annually. Licensee to email 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	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: DELIGHTFUL LIVING TOO	FACILITY NUMBER: 306005166
	VISIT DATE: 08/12/2024

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
26
27
28
29
30
31
32

bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate.

Based on this inspection, one deficiency was observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies.

This report was reviewed with facility representative and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3