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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005411
Report Date: 03/04/2025
Date Signed: 03/04/2025 05:29:36 PM

Document Has Been Signed on 03/04/2025 05:29 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:FORTITUDE RESIDENTIAL CAREFACILITY NUMBER:
306005411
ADMINISTRATOR/
DIRECTOR:		REBEKAH HAYESFACILITY TYPE:
735
ADDRESS:9852 OMA PLACETELEPHONE:
(310) 938-0700
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 4CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Enrique ManabatTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by DSP Staff, Nilda Bognot and explained the reason for the visit. Administrator (AD) Enrique Manabat arrived shortly to assist with the visit. The facility is licensed for four ambulatory clients. Currently there are four clients.

LPA Tea reviewed four client files and two staff files. There were discrepancies noted in the review of resident and staff files. Administrator certificate is pending renewal but has completed and complied with all course work for the administrator certificate.

LPA Tea and AD Manabat toured the facility at around 2:54 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of four client bedrooms, one staff room, three bathrooms, living room, dining room, staff office area, recreational activity area, kitchen and an attached garage. LPA observed smoke detectors/carbon monoxide in client bedrooms, and they are operational. There are cameras with no audio recording in the common area for security purposes. Client bedrooms had the required furniture, 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 105.4 degrees F to 107.7 degrees F. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA Tea observed sharps locked and secured in a drawer. Toxins were secured underneath the kitchen sink and a shed in the backyard. The fire extinguisher in the living room was fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating in the backyard. LPA observed emergency food and water supply in a cabinet in the dining room area. The staff provides activities like recreational exercises and small outings. They also have backyard BBQs for the clients to enjoy.

Annual report continuation on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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 5
Document Has Been Signed on 03/04/2025 05:29 PM - It Cannot Be Edited


Created By: Michael Tea On 03/04/2025 at 04:28 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: FORTITUDE RESIDENTIAL CARE
FACILITY NUMBER: 306005411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of client records there were no admission agreeements in the client files. This poses as a potential risk to personal rights of clients in care.
POC Due Date: 03/25/2025
Plan of Correction
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Facility will send copies of admission agreement, signed by client or representative to LPA by POC due date.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs review of client records there were no appraisal forms like preappraisals, needs and services forms filled out and completed and personal rights forms were missing as well. This poses as a potential health and safety risk to clients in care.
POC Due Date: 03/25/2025
Plan of Correction
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Facility will provide proof of completed pre-appraisals, needs and services, and personal rights forms to LPA by POC 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/04/2025 05:29 PM - It Cannot Be Edited


Created By: Michael Tea On 03/04/2025 at 04:28 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: FORTITUDE RESIDENTIAL CARE
FACILITY NUMBER: 306005411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of facility records. There were no records of recent disaster drills conducted. The last one LPA saw was done in Jan 2024. This poses as a potential risk to the health and safety of clients in care.
POC Due Date: 03/25/2025
Plan of Correction
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Facility provide proof of most recent fire/disaster drill and will keep in a log for documentation 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 Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/04/2025 05:29 PM - It Cannot Be Edited


Created By: Michael Tea On 03/04/2025 at 04:36 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: FORTITUDE RESIDENTIAL CARE
FACILITY NUMBER: 306005411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
80066(a)(6)
Personnel Records ... The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: Documentation of ... training and/or experience specified in licensing regulations for the type of facility in which the employee works.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of personnel records there are no records of current staff training. This poses a potential risk to the health and safety of residents in care.
POC Due Date: 03/25/2025
Plan of Correction
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Facility will provide proof of staff training or some kind of log documentation 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 Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: FORTITUDE RESIDENTIAL CARE
FACILITY NUMBER: 306005411
VISIT DATE: 03/04/2025
NARRATIVE
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At the time of the visit, clients were coming back from the day program and relaxing and enjoying snacks and water.

LPA reviewed medication storage and administration. Medications are stored in a locked closet by the front entry way. Medications are being administered per physician order. Client P&I Funds were reviewed, there were no discrepancies noted. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Enrique Manabat and a copy of these reports were given to the facility along with a copy of the LIC858; 859;809-D, and Appeal Rights

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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