306005261-8-16-2022-22-AS-ETAA-CHCQYR-20220816123535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005261
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:35:57 PM

Document Has Been Signed on 08/16/2022 12:35 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:	SWEETWATER SENIOR CARE		FACILITY NUMBER:	306005261
ADMINISTRATOR:	SALEEM MOOSANI		FACILITY TYPE:	740
ADDRESS:	5741 SWEETWATER PLACE		TELEPHONE:	(714) 496-7842
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS:	DATE:	08/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Paola Olivares, Hashim Moosani		TIME COMPLETED:	12:50 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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Paola Olivares and stated the purpose of this visit. Manager Hashim Moosani came during the visit and provided assistance. The facility is a single level structure and licensed for 4 ambulatory of which 2 can be non-ambulatory. This facility provides Residential Care Facility for the Elderly. At about 9:35 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 residents in care and 3 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms 1 of which was a shared room. Facility also had a staff room which is inaccessible to residents. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide alarms were tested to be operational. LPA noticed auditory exit alarms were not operational. Manager was made aware of this and will replace auditory alarms. LPA also noticed shelf in hallway closet was broken. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 108.6 degrees Fahrenheit. LPA did notice razor blades, a pair of scissors and medication in bathroom. Staff immediately removed items from residents in care. Bathroom (2) was observed to be in good repair and provided with grab bars and is designated for staff only. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies were inaccessible to residents in care. LPA noticed PUB 475 sign was not in 20x26 inches in size. Facility did not have adequate supplies of personal protective equipment in place. Manager will get enough PPE for facility. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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 08/16/2022 12:35 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: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by: The following requirements shall apply to medications which are centrally stored: 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.
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in two out of two medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2022
	Plan of Correction
1 2 3 4	Manager immediately removed medication making inaccessible to residents in care. Manager will also install a lock for medication.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
	VISIT DATE: 08/16/2022

NARRATIVE

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LPA notice there was no shade for outdoor furniture. Manager was made aware of this issue and will provide shade for outdoor furniture. LPA noticed the gate to the backyard door was not self-latching. LPA also notice backyard fence was not in good repair and some of the fence provided an opening. LPA also notice fence around the pool had an opening but was made inaccessible to residents in care. LPA made Manager aware of this and will have items fixed or replaced. Garage is kept locked and is inaccessible to residents in care. Facility offers a 3-car garage which is used for storage with an operational washer and dryer and 2 refrigerators. LPA Tapia noticed medication stored in an unlocked refrigerator. LPA Tapia made Manger aware of citation.
Kitchen was in good repair with knifes kept locked and inaccessible to residents. LPA did notice medication in refrigerator. Manager immediately removed medication making it inaccessible to residents.
LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, one deficiency was noted in areas observed. No citation was issued. Five advisories were issued today.

LPA Tapia conducted an exit interview with Manager Hashim Moosani and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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