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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005352
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:35:00 PM


Document Has Been Signed on 08/25/2022 12:35 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:DIGNITY & WISDOMFACILITY NUMBER:
306005352
ADMINISTRATOR:TESFAY, SABAFACILITY TYPE:
740
ADDRESS:17331 VINEWOOD AVENUETELEPHONE:
(714) 368-9058
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 6DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregivers JR Reblora and Susan Pineda and explained the reason for the visit. During visit Administrator Saba Tesfay arrived at at 12:18 PM.

At 11:30 AM, LPA toured the facility with Caregiver Susan Pineda. Facility is 5 bedroom, 3 bathroom single story home with a detached garage. Facility has 6 residents present during today's visit. LPA observed residents eating lunch in dining room. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed bed rails on 5 out of 6 resident's beds without physician orders. The facility mitigation plan has been completed and approved. LPA observed emergency food and water. LPA observed locked medication cabinets. LPA toured the outside grounds and observed outside shaded visitation area. Exit gate is unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA reviewed all residents files and all contained required documentation including updated emergency information. All staff and residents are vaccinated for Covid 19.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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 08/25/2022 12:35 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: DIGNITY & WISDOM
FACILITY NUMBER: 306005352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608(a)(3) Postural Supports. Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from the physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 5 out of 6 persons which poses a potential personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Licensee to obtain physicains orders for postural supports and forward proof to LPA by POC due date.
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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
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