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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005439
Report Date: 09/17/2024
Date Signed: 09/18/2024 08:26:52 AM


Document Has Been Signed on 09/18/2024 08:26 AM - 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CARE JORDAN SENIOR HOMESFACILITY NUMBER:
306005439
ADMINISTRATOR:GIDEON LIMPIADOFACILITY TYPE:
740
ADDRESS:8728 CANARY AVENUETELEPHONE:
(562) 365-4155
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Sara Jane - House ManagersTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the
purpose of conducting a required annual inspection. LPA was greeted at the facility by Sara Jane, House Manager. LPA met with Gideon Limpiado, Administrator via phone call and explained the purpose of
the inspection.
The facility is one-story building with five resident bedrooms, two resident bathrooms, living room, den, kitchen, dining room, laundry room, two caregiver rooms, attached 2-car garage and backyard. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. LPA noted residents were lounging in their rooms or the living room.
All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in a a closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced on March 16, 2024. Smoke/Carbon Monoxide detectors were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen or garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a closet in the living room. The backyard has a shaded sitting/lounging areas. Exit gate is unlocked. LPA observed exit gate to be unobstructed. Based on record review, LPA observed facility staff present at the facility did not have current CPR certifications in their file. LPA observed facility does not have exception request for bed rails for two residents with bed rails longer than half. These residents are not on hospice. LPA observed facility does not have a physician's order for bed rails that are longer than half. Three citations are being issued. LPA issued Technical Violation advising facility to draft a dementia care plan and a hospice care plan. LPA reviewed three resident files and three staff files. LPA also reviewed medication for three residents. LPA interviewed one staff and one resident.
Based on today's inspection, three deficiencies and two technical violations are being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 09/18/2024 08:26 AM - 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CARE JORDAN SENIOR HOMES
FACILITY NUMBER: 306005439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to none of the staff present at the time of the inspection having a current CPR certification which poses an immediate safety risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Administrator stated at least one staff member will complete their CPR certification. Administrator will send CPR card to LPA via email by the assigned 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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/18/2024 08:26 AM - 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CARE JORDAN SENIOR HOMES
FACILITY NUMBER: 306005439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) 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 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observation, the licensee did not comply with the section cited above in one two out of six residents which poses a potential personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Facility staff stated they will obtain a physician's order for the resident's bed rails or remove the bed rails from their bed by the assigned POC due date. Facility staff will email LPA the physician's order if that is obtained or facility staff will email LPA photos of the bed with the bed rails removed if that is done. These emails will be sent to the LPA by the assigned POC due date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(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 review, the licensee did not comply with the section cited above in two out of six residents which poses potential personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Administrator stated they will send to LPA via email their Exception Request for bed rails by the assigned 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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3