306005261-8-15-2024-22-AS-EKIM-D86PRJ-20240815113249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005261
Report Date: 08/15/2024
Date Signed: 08/15/2024 11:33:02 AM

Document Has Been Signed on 08/15/2024 11:33 AM - 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:	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: 5	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Hashim Moosani		TIME COMPLETED:	11:40 AM

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

On August 15, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Assistant Administrator (AA) Hashim Moosani and explained the purpose of the visit.

The facility is licensed to operate for four (4) ambulatory residents and two (2) non-ambulatory residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) Staff bedroom, two (2) bathrooms, living room, family area, dining room, kitchen, attached 3-car garage, swimming pool, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with AA Moosani. There are no obstructions on premises. There is a swimming pool located in the backyard that is enclosed with a fence which makes it inaccessible for the residents. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Staff Room 1 Bathrooms were found to be clean.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly Emergency food and emergency water is stored in the kitchen pantry. A working telephone (714-660-9268) remains available. First Aid Kit contained all the necessary elements. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 4

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: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
	VISIT DATE: 08/15/2024

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

This page was amended due to technological error not having the Assistant Administrator Hashim Moosani digital signature. AA Moosani signed digitally but the final recorded original did not print with the signature.

Due to time constraint a continuation of this inspection will be conducted at a later date. LPA Kim will: 1) conduct record review for staff and residents, 2) Conduct interviews with staff and residents, 3) conduct a medication review at a later date and 4) review fire/safety drill log.

Deficiencies were cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6 Chapter 8).

An exit interview was conducted and a copy of this report and the appeal rights were provided to Assistant Administrator Hashim Moosani

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 08/15/2024 11:33 AM - 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: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed water temperature in bathroom 1 to measure at 136.5 degrees Fahrenheit and bathroom 2 measure at 142.8 degrees Fahrenheit.This 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 states they will fix the water temperature to be in regulation. Licensee will send photos of water temperature in regulation range of 105 degrees F and 120 degrees F and a water temperature log from August 15, 2024 5:00pm to August 16, 2024 to CCLD via email edward.kim@dss.ca.gov by POC due Date August 16, 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: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/15/2024 11:33 AM - 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: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above LPA observed bed frame, displaced fence in the right side of the house, panel of glass, wood plank, chair, and water heater. The entrance doorbell was not working properly.This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	Licensee states they will fix the doorbell and the displaced fence and setup appointment with Waste Management to pickup panel of glass, the wood plank, chair, and water heater to pickup before August 30, 2024. Licensee will send photo of fixed fence, a video of working doorbell, and photo of cleared items to CCLD via email edward.kim@dss.ca.gov by POC due Date August 30, 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: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4