<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005431
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:47:09 PM

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:SENIOR ASSISTED CARE HOMESFACILITY NUMBER:
306005431
ADMINISTRATOR:MARK STRAUSSFACILITY TYPE:
740
ADDRESS:2609 SANTA YSABELTELEPHONE:
(818) 631-3474
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 2DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Thomas DuffyTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with House Manager (HM) Thomas Duffy and discussed the purpose of the inspection. During the inspection, LPA and HM conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

LPA and HM observed there were 2 staff present, wearing PPE. LPA observed 2 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen, and observed they were clean and organized. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

During the inspection, LPA and HM observed the following: in the kitchen, knives and toxins were accessible to residents in non-lockable cabinets and drawers. During the inspection, HM properly secured all of these items.
LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA provided technical assistance regarding visitation, outings, N95 fit testing, facility records, and resident records. LPA requested and reviewed resident roster, staff roster, staff files, resident files, and emergency plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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 7
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: SENIOR ASSISTED CARE HOMES
FACILITY NUMBER: 306005431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation: (a) The facility shall be clean, safe.... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not ensure knives and toxins were inaccessible to residents in the kitchen, which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/27/2021
Plan of Correction
1
2
3
4
Licensee immediately secured the knives and toxins during today's inspection and LPA confirmed
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7