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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005385
Report Date: 02/26/2024
Date Signed: 02/26/2024 05:23:38 PM


Document Has Been Signed on 02/26/2024 05:23 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ORANGE COUNTY CARE HOME IIFACILITY NUMBER:
306005385
ADMINISTRATOR:RASSOULI ZADEHEI, FAHIMEHFACILITY TYPE:
740
ADDRESS:27561 ALMENDRA DRIVETELEPHONE:
(949) 322-1078
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Faith Rassouli, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Faith Rassouli was contacted by phone and arrived later to assist with the visit.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-level home with six resident bedrooms, one staff room and three full bathrooms. All resident bedrooms have the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded sitting area and the route of egress is free of clutter and obstructions. There are currently six residents in care at the facility, one of which is receiving hospice care. Bathrooms faucets and toilets were operational. Water temperature tested at approximately 110F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Sharps were observed locked in a drawer in the kitchen. LPA observed cleaning supplies to be stored in a locked cabinet under the kitchen sink. The laundry area is also observed to be secured. The medication central storage was observed to be locked. LPA reviewed six resident files and four staff files before conducting staff and resident interviews.

Based on the observations made during today’s inspection, three type B deficiencies are being cited along with two Technical Assistance and one Technical Violation Advisory Notes per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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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Document Has Been Signed on 02/26/2024 05:23 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the facility visit, the licensee did not comply with the section cited above in one instance of supplements being left accessible in the room of a resident. The resident is not diagnosed with dementia but other residents are, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Licensee will secure supplements and ointments (such as Voltarene and Calmoseptine) with the rest of the facility's medication central storage.
Type B
Section Cited
CCR
87465(h)(5)
Per the Calfornia Code of Regulations Section 87465(h)(5): "The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during a tour of the physical plant and an interview with the administrator, the licensee did not comply with the section cited above as medication has been prepared in advance until February 28, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Licensee will update staff training on medication dispensation and ensure that pre-pouring does not occur for periods of over 24 hours. Proof of training to be provided to LPA before the Plan of Corrections due date.
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 02/26/2024 05:23 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)
Per CCR Section 87608(a) on Postural Supports: "Postural supports may be used under the following conditions:
(3) A written order from a 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. (...)
(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviewed during the facility visit, the licensee did not comply with the section cited above in three instances. Two residents have beds with half rails with no physician order and one bed is equipped with full rails in spite of the resident not being on hospice. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Licensee will get the unused full rails removed and obtain physician orders for the half rails seen in use in the facility. A copy of the orders will be provided to the Department before the plan of corrections 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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