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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005360
Report Date: 11/04/2024
Date Signed: 11/04/2024 03:44:06 PM

Document Has Been Signed on 11/04/2024 03:44 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:ASTORIA SENIOR CARE HOMES AT MONARCH BAYFACILITY NUMBER:
306005360
ADMINISTRATOR/
DIRECTOR:		ABRUDAN, OANA MARIAFACILITY TYPE:
740
ADDRESS:32622 AZORES ROADTELEPHONE:
(714) 299-9527
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Jason David and Aris JugoTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Astoria Senior Care at Monarch Beach. The purpose of today’s visit was to conduct the annual required inspection. LPA was allowed entry into the home and met with Caregiver Jason David. House Manager Aris Jugo arrived during the visit. Facility is licensed for 4 non-ambulatory residents and 2 ambulatory residents. Facility has an approved hospice waiver for 4 residents and the home currently has 5 residents, with 4 residents on hospice. Administrator Oana Abrudan has an administrator certificate expiring on 01/07/2025.

LPA Lyman along with Caregiver Jason David toured the facility at 10:50 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 6 resident bedrooms, living room, dining room, and kitchen as well as a staff room/ bathroom and 3 shared bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 118.2 degrees F and 123.8 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Auditory exit alarms are operational during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed kitchen knives locked in a kitchen cabinet as well as cleaning supplies locked under the sink. Kitchen appliances are operational during today's visit. The garage is locked and has an alarm on the door. Smoke detectors and carbon monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control plan and plan is complete. Facility conducts quarterly emergency drills with the last drill conducted on 10/07/2024. Outside grounds were toured. LPA observed a fenced pool in the backyard. Pool gate is locked and pool is inaccessible to residents in care. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. CONTINUED ON LIC 809C DATED 11/04/2024.

Alisa OrtizTELEPHONE: (714) 703-2855
Kimberly LymanTELEPHONE: (714) 795-1497
DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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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: ASTORIA SENIOR CARE HOMES AT MONARCH BAY
FACILITY NUMBER: 306005360
VISIT DATE: 11/04/2024
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There is ample outdoor seating for residents. Exit gate is unlocked and self latching. LPA observed the emergency food and water supply. LPA reviewed five resident files and three staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen. Medications are being administered per physician order.



Licensee has been asked to provide an updated LIC 500 (Personnel report), LIC 610 (Emergency Disaster Plan), and LIC 308 (Designation of Facility Responsibility) by 11/18/2024.

Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 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) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 11/04/2024 03:44 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: ASTORIA SENIOR CARE HOMES AT MONARCH BAY
FACILITY NUMBER: 306005360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Licensee to adjust water temperature 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) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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