306005321-9-9-2022-22-AS-ETAA-CJ4TDW-20220909143901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005321
Report Date: 09/09/2022
Date Signed: 09/09/2022 02:40:42 PM

Document Has Been Signed on 09/09/2022 02:40 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:	ORANGE VIEW ELDERLY CARE		FACILITY NUMBER:	306005321
ADMINISTRATOR:	RODRIGUEZ, FRANCIS		FACILITY TYPE:	740
ADDRESS:	2431 E ORANGEVIEW LANE		TELEPHONE:	(949) 463-6501
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 5	DATE:	09/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Josephine Vegas, Josephine Nieva, Carmen Rodriguez		TIME COMPLETED:	02:50 PM

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	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Josephine Vegas, Josephine Nieva and stated the purpose of this visit. Administrator Carmen Rodriguez arrived after the inspection. The facility is a single level structure and licensed for six non-ambulatory with a hospice waiver for three. This facility is a Residential Care Facility for the Elderly/Dementia. At about 1:20 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 5 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 6 resident rooms 1 of which was vacant. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 107.0 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies are inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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 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: ORANGE VIEW ELDERLY CARE	FACILITY NUMBER: 306005321
	VISIT DATE: 09/09/2022

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

For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Garage is kept locked and used for storage with an operational washer/dryer and freezer and refrigerator. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. Kitchen was in good repair. LPA did notice broken locks for the knifes. Administrator was made aware of this and will purchase locks for sharps. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, 1 deficiency was noted in areas observed. No advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Carmen Rodriguez and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/09/2022 02:40 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: ORANGE VIEW ELDERLY CARE	FACILITY NUMBER: 306005321
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

This requirement is not met as evidenced by: The following shall be stored inaccessible to residents with dementia. Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 2 out of 2 drawers where knifes were found which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/10/2022
	Plan of Correction
1 2 3 4	Administrator will purchase locks for drawers containing knifes.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3