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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005287
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:27:17 PM


Document Has Been Signed on 10/11/2023 03:27 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:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Roy Santa Ana - AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at Ameriheart Care Home to conduct an unannounced Required 1 Year Inspection. LPA arrived at the facility at 1:25pm, LPA was greeted and granted entry by Caregivers (CG) Melchor Santos and Rowena Daileg. Administrator (AD) Roy Santa Ana joined the inspection at 1:35pm.

The facility is a one-story home with four bedrooms, two bathrooms, living room, kitchen, dining room, backyard, two staff bed/bathrooms, laundry area and an attached two car garage. The garage is used as an office. There is one exit gate the side of the house and one seating area in the backyard. LPA did not observe hazards or obstacles in back yard. Resident bedrooms had the required furnishings. LPA observed resident beds had linens and blankets. LPA observed windows were screened. All toxic chemicals, cleaning solutions and disinfectants are locked in cabinets in the kitchen/laundry area. Medication, First Aid Kit and Files are stored in a locked closet in the entryway. LPA reviewed two out of five client files and medication. LPA reviewed three staff files. LPA interviewed two clients. Other clients were unavailable at the time. The fire extinguisher is fully charged. LPA observed service tag to indicate the extinguisher was last serviced on 12/22/22. For activities, the facility has books, games and goes on outings. All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 107 degrees Fahrenheit in the bathroom near bedroom 1 and 105.9 degrees Fahrenheit in the bathroom near bedroom 6. A supply of extra linen and hygiene supplies was stored in the hallway cabinets. Emergency Phone Numbers, Exit Plan & Menu are posted and available for review. There is a 2-day supply of perishable food and 7-day supply of non-perishable food on hand. Smoke and carbon monoxide detector tested operational. Gas stove, burners, oven, refrigerators, dish washer, microwave, washer and dryer are operational. Based on Record Review, LPA determined facility has a past-due balance of annual fees. A deficiency is being given on this day.
Based on the observations made during today's visit, one deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administrator Roy Santa Ana, and a copy of this report was provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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 10/11/2023 03:27 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: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80036(a)
An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility has an overdue balance of annual fees. This poses an potential health risk to persons in care as ongoing failure to pay fees can result in facility closure.
POC Due Date: 11/10/2023
Plan of Correction
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Administrator made payment electronically during LPA's visit. Administrator stated they will send to LPA via email, confirmation of payment before POC due date 11/10/23. LPA will verify this plan of correction via the Licensing Information System (LIS) by the assigned POC due date of 11/10/23.
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: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
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