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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005338
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:12:02 PM

Document Has Been Signed on 09/15/2022 02:12 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:STEADFAST WESTERN AVEFACILITY NUMBER:
306005338
ADMINISTRATOR:SUSIEROSE ABELLAFACILITY TYPE:
735
ADDRESS:6052 WESTERN AVETELEPHONE:
(310) 809-3427
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 2DATE:
09/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Susierose Abella TIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management. LPA was greeted, granted entry, and explained the reason for the visit. Staff called Administrator (AD) Abella via telephone.

The purpose of today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC624) that was emailed to LPA Haley and the Orange County Adult and Senior Care Program Regional Office September 13, 2022 that involved Client 1 (C1).

AD Abella and Licensee Francine Penalosa arrived to speak with LPA Haley regarding the incident.

During the visit LPA Haley received copies of C1's Face sheet and Physician's Report. AD Abella will be emailing LPA Haley C1's Admission Agreement and Individualized Service Plan.

Deficiencies are being cited during today's Case Management visit. An exit interview was conducted, a copy of the LIC811 this report and appeal rights was provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 09/15/2022 02:12 PM - It Cannot Be Edited


Created By: Jerome Haley On 09/15/2022 at 01:26 PM
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: STEADFAST WESTERN AVE
FACILITY NUMBER: 306005338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited
CCR
80078(a)

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Responsibility for providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not being met as evidenced by.
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Licensee has installed an alarm on the back door and the employee who fell asleep has been terminated.
Facility Management and some staff will attending "Get Safe" a webinar, September 16, 2022. Licensee will send proof of attendance to LPA by POC due date.
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Based on interview confirmation, and review of the incident report sent to the Orange County Regional Office, staff fell asleep on the job, and failed to comply with the regulation cited above.

This poses an immediate health and safety risk to residents in care.
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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:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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