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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005301
Report Date: 07/28/2022
Date Signed: 07/28/2022 01:09:26 PM

Document Has Been Signed on 07/28/2022 01:09 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:AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTHFACILITY NUMBER:
306005301
ADMINISTRATOR:CINDY TAMAYOFACILITY TYPE:
772
ADDRESS:25402 PACIFICA AVENUETELEPHONE:
(949) 238-2400
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. Via phone, LPA spoke with Administrator (AD) Jacqueline Lara and stated the purpose of this visit.

After completing the Coronavirus 2019 (COVID 19) screening procedure, LPA Marin was granted entry in the facility. This facility is a two-level structure and licensed for six ambulatory For this visit, LPA observed five clients in care and three staff members on the floor. Three client’s shared rooms are located on the upper level. Rooms were provided with furniture in good repair, clean linens and kept free of tripping hazards. Smoke and carbon monoxide alarms were tested to be operational. Medication and office room is located also in the upper level and rendered inaccessible to unauthorized access. Common bathroom in each level was provided with water fixtures and observed to be in good repair. Hot water was measured at 120 degrees Fahrenheit. On the ground level are the common areas and provided with furniture in good repair. Facility met the minimum 2-day perishable and 7-day perishable food stock requirements. Personal protective equipment were observed to be in place. For the exterior portion, facility had a pool feature enclosed by steel fence system and rendered inaccessible to clients in care. Outside furniture were provided and observed to be in good repair. Grounds were free of tripping hazards.

For this visit, LPA Marin observed the following deficiencies ; and issued citations per Title 22 Division 6 of the California Code of Regulations:
  • At 9:51 AM, LPA observed unlocked under-sink cabinet containing partially filled containers of hand and dishwashing soaps, and cleaning supplies.
  • At 9:53 AM, LPA observed a flank of wood (about 3 feet in length and 1 foot in wide) placed over the track of the sliding door. This piece of wood prevented the sliding door from opening. The dining sliding door was identified as an exit in the posted evacuation plan.
  • At 10:08 AM, LPA observed a broken window screen panel off the window in Room No. 2
  • At 10:20 AM, LPA observed that each client’s bed in Room No. 2 was missing a box spring.

(Continuation in Page 2)
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301
VISIT DATE: 07/28/2022
NARRATIVE
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Continuation from Page 1

LPA also discussed Assembly Bill 665 for which the facility is already providing desktop computer and wireless internet access to clients in care. LPA also reminded AD of the infection control plan of the facility as described by Provider Information Notice 22-13-ASC. LPA directed AD to send all incident reports to CCLASCPOrangeCountyRO@dss.ca.gov

LPA Marin conducted a phone exit interview with AD Lara. LPA discussed the deficiencies observed, the citations and advisory notes issued, immediate civil penalty assessment and the appeal rights. AD gave permission for staff member to sign and receive the reports. Copies of this report, deficiency page, advisory notes, civil penalty assessment form, and cited regulations were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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Document Has Been Signed on 07/28/2022 01:09 PM - It Cannot Be Edited


Created By: Albert Marin On 07/28/2022 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81023(b)(2)(A)

81023 Disaster and 81023 Disaster and Mass Casualty Plan: The plan shall be subject to review by the licensing agency and shall include: (2) Contingency plans for action during fires, floods, and earthquakes, including but not limited to the following:(A) Means of exiting.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility missed to provide means of exiting the facility in an event of a disaster. LPA observed a flank of wood (about 3 feet in length and 1 foot in wide) placed over the track of the sliding door. This piece of wood prevented the sliding door from opening. The dining sliding door was identified as an exit in the posted evacuation plan. This poses an immediate threat on the safety of the clients in care.
POC Due Date: 08/29/2022
Plan of Correction
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Facility immediately removed the piece wood from the track of the sliding door. Immediate threat reduced. As plan of correction, AD agreed to

Immediate civil penalty was assessed on this visit.
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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


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Document Has Been Signed on 07/28/2022 01:09 PM - It Cannot Be Edited


Created By: Albert Marin On 07/28/2022 at 11:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(i)(1)

81088 Fixtures, Furniture, Equipment, and Supplies. The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.(1) An individual bed, except that couples shall be allowed to share one double or larger size bed, maintained in good repair, and equipped with good bed springs, a clean mattress, and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility missed to provide individual bed and maintained in good repair and equipped with a good bed spring. At 10:20 AM, LPA observed that each client’s bed in Room No. 2 was missing a box spring. This poses immediate threat on the personal rights of the client in care.
POC Due Date: 08/11/2022
Plan of Correction
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AD stated that the facility promise to provide new box spring to each bed in Room 2. Threat reduced. Proof of correction will be submitted to Community Care Licensing Division (CCLD) on or before August 11, 2022
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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


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Document Has Been Signed on 07/28/2022 01:09 PM - It Cannot Be Edited


Created By: Albert Marin On 07/28/2022 at 11:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(b)
81088 Fixtures, Furniture, Equipment, and Supplies. (b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility miss to maintain all window screens in good repair and be free of insects and other debris. At 10:08 AM, LPA observed a broken window screen panel off the window in Room No. 2. This poses potential threat against the health and safety of the clients in care.
POC Due Date: 08/11/2022
Plan of Correction
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As plan of correction AD will provide proof of correction to Community Care Licensing Division on or before August 11, 2022.
Type B
Section Cited
CCR
81087(l)

81087 Buildings and Grounds (l)The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions, and poisons are stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility missed to ensure that cleaning solutions were not readily available to clients. At 9:51 AM, LPA observed unlocked under-sink cabinet containing partially filled containers of hand and dishwashing soaps, and cleaning supplies. This poses potential threat on the health and safety of the clients in care.
POC Due Date: 08/11/2022
Plan of Correction
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As plan of correction, AD will provide training to all staff members on ensuring that all cleaning supplies and toxins are not accessible to clients in care at all times. Proof of correction will be submitted to Community Care Licensing Division on or before 08/11/22.
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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


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