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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005287
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:26:28 PM


Document Has Been Signed on 07/30/2024 12:26 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:AMERIHEART CARE HOMEFACILITY NUMBER:
306005287
ADMINISTRATOR:YCASAS, TIMOTHYFACILITY TYPE:
740
ADDRESS:9622 KATELLA AVENUETELEPHONE:
(714) 733-8095
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Roy Santa Ana - Administrator TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of
conducting a required annual inspection. LPA was greeted and granted entry into facility by Caregiver Rowena Daileg. LPA met with Administrator Roy Santa Ana and explained the purpose of the inspection.

The facility is a one-story home with five resident bedrooms, two bathrooms, staff room, kitchen, dining room, living room, backyard with patio and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted residents were lounging in their own rooms or away at Day Program.

All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility
has extra linens and hygiene supplies for residents in the hallway closet. Restrooms are stocked with soap
and paper towels and have hand washing postings. Hot water initially measured above 120 degrees F. A
deficiency is being issued. Administrator adjusted water heater resulting in hot water measuring between
105 and 120 degrees F. LPA advised AD to maintain a water log to ensure water temperature remains in compliance. LPA observed facility has emergency food and water supply. LPA observed the fire
extinguisher was last serviced on December XX, 2023. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the entryway. The backyard has a shaded sitting/lounging area. Exit gate is unlocked and self latching. LPA observed exit gate to be unobstructed. LPA reviewed three resident files and three staff files. LPA also reviewed medication for three residents. LPA interviewed one staff and one resident. LPA observed 20" x 26" PUB475 posted in entryway.

Based on Title 22 Division 6 of the California Code of Regulations, one deficiency is being issued based on
today's inspection. An exit interview was conducted and a copy of this report was provided to the facility
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 07/30/2024 12:26 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: AMERIHEART CARE HOME
FACILITY NUMBER: 306005287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

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
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Based on observation, the licensee did not comply with the section cited above due to hot water in resident bathrooms measuring over 120 F degrees which poses an immediate safety risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Facility staff adjusted the hot water heater during the inspection. Hot water measured between 105 and 120 degrees Fahrenheit during the inspection. This deficiency was corrected during the annual.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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