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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005263
Report Date: 03/18/2024
Date Signed: 03/18/2024 01:58:59 PM


Document Has Been Signed on 03/18/2024 01:58 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:FAMILY FIRST HOME CARE INCFACILITY NUMBER:
306005263
ADMINISTRATOR:DERRICK, LISAFACILITY TYPE:
740
ADDRESS:10675 LYNN CIRTELEPHONE:
(562) 261-6218
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 6DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Nancy Runjugi, Caregiver and Christine Link, CaregiverTIME COMPLETED:
02:00 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called and spoke to Licensee/Administrator (L/AD) Lisa Derrick who indicated being out of state due to a Family emergency and available via telephone.
This is a a Residential Care Facility for the Elderly, licensed to provide services to six(6) Non Ambulatory residents and has a hospice waiver for (3) three residents. There are currentl six (6) residents in care at this time of which 3 are receiving hospice care services. There are no active COVID-19 cases in the facility at this time. Administrator Lisa Derrick has an Administrator Certificate with expiration date of May 4, 2024.
LPA Quiroz along with (CG1) toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed 6 of 6 Residents interacting with staff in living room area and eating lunch consisting of: Grilled cheese sandwich, macaroni salad, orange slices and water. LPA Quiroz interacted and interviewed with Caregivers and 6 of 6 residents during today's visit.
LPA Quiroz inspected resident's bedrooms and bathrooms. The water temperature in 2 of 2 resident's bathrooms were recorded to be between 116.8-118.4 degrees Fahrenheit. LPA Quiroz inspected resident's bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has limited supply of emergency food, water and PPE in the garage area readily available for staff and residents in care. Fire extinguisher observed last serviced on 10/2023. LPA Quiroz observed functional and operational washer and dryer in the garage area. LPA Quiroz toured the outside of the facility and observed seating and shaded area in the backyard for residents and visitor's enjoyment.
LPA Quiroz not able to review resident and personnel records due to locked and secured files, and staff not having key to the files. This was verified with (L/AD) Derrick who indicated "I'm out of state and the staff don't have access to the files." (See LIC 809-D) CONTINUED LIC 809-C...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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 03/18/2024 01:58 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: FAMILY FIRST HOME CARE INC
FACILITY NUMBER: 306005263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506(a): The licensee shall ensure that a separate, complete and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by: 6 of 6 resident records were not readily available for LPA Quiroz to review during today's visit due to files being locked and secured. AD Derrick verified indicating being out of state and staff present at the facility not having access to resident files.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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(AD) Derrick agreed to read CCR 87506, submit proof of understanding and maintain resident files key in the facility readily available for staff at the facility.
Type B
Section Cited
CCR
87412(f)

Personnel Records 87412(f): All personnel records shall be available to the licensing agency to inspect, audit and copy upon demand during normal business hours.
This requirement is not met as evidenced by: Personnel records were not available for LPA Quiroz to review during today's inspection visit. (AD) Derrick indicated being out of state and facility staff not having access to personnel records at this time.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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(AD) agreed to read and understand CCR 87412: Personnel Records and have key to personnel records readily avaialble for staff working at the facility.
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: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FAMILY FIRST HOME CARE INC
FACILITY NUMBER: 306005263
VISIT DATE: 03/18/2024
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CONTINUED...During today's facility tour, the following were not observed: Facility license and PUB 475 Poster "If you see something say something." This was verified with (L/AD) Derrick (SEE LIC 9102-TV)

During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control. An exit interview was conducted with (AD) Derrick and a copy of this report, LIC 809-D pages, Appeal Rights, LIC 9102-TV and LIC 811- Confidential names, were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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