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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005174
Report Date: 09/09/2022
Date Signed: 09/09/2022 02:09:02 PM


Document Has Been Signed on 09/09/2022 02:09 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:SAN CLEMENTE CARE HOMEFACILITY NUMBER:
306005174
ADMINISTRATOR:CASTEN, LUISITOFACILITY TYPE:
740
ADDRESS:2927 BONANZATELEPHONE:
(310) 975-5634
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Anjelica Valle and Mercy AngTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Anjelica Valle and explained the reason for the visit. Administrator Luisito Casten has an administrator certificate expiring on 02/04/2024. Administrators Joanne Casten and Mercy Ang arrived during the visit.

At 12:41 PM, LPA toured the facility with Administrator Mercy Ang. Administrator Joanne Casten joined the tour in progress. Facility has 6 residents in care during today's visit, with 2 on hospice care. Facility has bedridden fire clearance for one resident. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. At 12:50 PM, LPA observed the medication closet is unlocked and medications are accessible to residents in care. All resident rooms are single occupancy and had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening station. Facility takes staff and resident temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. Smoke detectors/ carbon monoxide detectors tested operational during today's visit. LPA toured the outside grounds and observed multiple shaded outside visitation areas. Exit gates are unlocked and self latching. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. Most residents and all staff are vaccinated for Covid-19.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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Document Has Been Signed on 09/09/2022 02:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SAN CLEMENTE CARE HOME
FACILITY NUMBER: 306005174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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. Medication closet is unlocked. This poses an immediate health and safety risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee to secure closet. Licensee secured closet during visit.
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) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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