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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005457
Report Date: 09/09/2024
Date Signed: 09/09/2024 02:17:53 PM


Document Has Been Signed on 09/09/2024 02:17 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:CARE CELINEFACILITY NUMBER:
306005457
ADMINISTRATOR:AGUILA, CHERRYFACILITY TYPE:
740
ADDRESS:1745 N BALLAD DRIVETELEPHONE:
(714) 801-5208
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Cherry Aguila- AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA met with Administrator Cherry Aguila and explained the reason for the visit.

Facility is licensed to serve six (6) non-ambulatory residents and maintains an approved hospice waiver for six (6) residents. There are four (4) residents in care during today's visit with two caregivers on duty. The Administrator's Certificate for Cherry Aguila expires on November 11, 2024.

LPA conducted a tour of the physical plant. This is a two story home in a residential neighborhood. The first floor consists of five resident bedrooms and two resident bathrooms. The second floor consists of two bedrooms and one bathroom which is occupied by one live-in staff. The second bedroom and bathroom is unoccupied. Residents do not occupy the second floor. LPA inspected all common areas including the attached two car garage. LPA observed the floor, bathrooms, and kitchen drawers require a deep cleaning. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be operational. The water temperature measured at 108.0 and 110.0 degrees Fahrenheit. Toxins, disinfectants, and medications were secured and inaccessible, however the sharps were unsecured in the oven as the locking mechanism for the knife drawer was not working properly at the time of inspection. Locking mechanism was repaired during the visit. LPA observed sufficient two day supply of perishables and seven day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstruction. LPA observed sufficient seating and shading. There was no body of water. Several sheds in the yard were utilized as storage which were secured and inaccessible to residents. Facility maintains two fire extinguishers one on each floor. Last service date was on September 19, 2023.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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 09/09/2024 02:17 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: CARE CELINE
FACILITY NUMBER: 306005457

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 and interviews, the licensee did not comply with the section cited above by having unsecured knives in the oven which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Administrator replaced the locking mechanism during the visit. POC corrrected and cleared.
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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2024 02:17 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: CARE CELINE
FACILITY NUMBER: 306005457

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observation, interview, and record review, facility did not ensure at least one out of the two staff on duty is CPR and First Aid certified which poses a potential Health or Safety to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Adminstrator stated that proof of CPR and First Aid training will be completed for S1 and S2 by POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, licensee did not maintain complete personnel records for two out of two staff which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator stated that the missing personnel records for S1 and S2 will be completed 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2024 02:17 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: CARE CELINE
FACILITY NUMBER: 306005457

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(e)(3)
Other Provisions
(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, licensee did not maintain employee training records for two out of two staff that were reviewed during the visit which poses a potential Health, Safety, or Personal risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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Adminstrator stated that S1 and S2 will meet the required training and will provide proof of documentation to LPA via email by POC due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, licensee did not conduct a pre-appraisal for four out of four residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator stated that pre-appraisals and re-appraisals (as needed) will be completed 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2024 02:17 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: CARE CELINE
FACILITY NUMBER: 306005457

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, licensee did not ensure a medical assessment was kept on file for one out of four residents which poses a potential risk to Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator stated that a medical assessment will be obtained for R2 by POC due date.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, licensee did not maintain a TB test exam results in one out of four residents in care which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Adminstrator stated that the TB test will be obtained for R2 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2024 02:17 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: CARE CELINE
FACILITY NUMBER: 306005457

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 observation, interview, and record review, licensee did not maintain a emergency drill log which poses a potential Health, Safety, or Personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Adminstrator stated that emergency drills accounting various scenarios will be conducted quarterly and willl maintain a log documenting the drills by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, licensee did not maintain an annual medical assessment for two out of four residents with dementia which poses a potential Health or Safety risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator stated that the physician's report forms will be updated for R1 and R3 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 6 of 10


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: CARE CELINE
FACILITY NUMBER: 306005457
VISIT DATE: 09/09/2024
NARRATIVE
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The auditory devices and smoke/carbon monoxide detectors were tested and operational except for one auditory device on the sliding door. LPA observed sufficient PPE and emergency disaster supplies including food/water in the garage. Emergency evacuation drills are not conducted quarterly and facility does not maintain a log documenting the drills. The first aid kit contains all necessary elements. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size. Facility maintains a current liability insurance. A working facility telephone number, (714) 340-0754, remains available. The annual licensing fee of $495.00 was paid on September 8, 2024.

LPA conducted an audit of four residents' files and two personnel files. Discrepancies were noted. Medications were audited for four residents. No discrepancies noted. Staff and resident interviews were also conducted.

The following items were consulted with Administrator Aguila: to replace battery for one auditory device on the sliding door, label expiration dates for all dried food items, deep clean the pantry drawers, bathrooms, and the floor for both levels, repair the light in the stairway that was flickering, post "Oxygen In Use, No Smoking signs for one bedroom and on the main door, complete/organize resident/personnel records, ensure staff training records are completed and maintained, to ensure at least one on duty staff is CPR/First Aid certified, to conduct quarterly evacuation drills, and to maintain a log.

Based on the observations made during today's visit, deficiencies are being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC9099-Ds. Advisory Notes are also being issued.

An exit interview was conducted with Administrator Cherry Aguila and a copy of this report including the LIC9099-C & Ds, Advisories, and the Appeal Rights were sent via email at the end of the visit.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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