306005457-9-19-2022-22-AS-JCHO-CJEUVB-20220919155453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005457
Report Date: 09/19/2022
Date Signed: 09/19/2022 03:55:06 PM

Document Has Been Signed on 09/19/2022 03:55 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CARE CELINE		FACILITY NUMBER:	306005457
ADMINISTRATOR:	AGUILA, CHERRY		FACILITY TYPE:	740
ADDRESS:	1745 N BALLAD DRIVE		TELEPHONE:	(714) 801-5208
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92807
CAPACITY:	6	CENSUS: 5	DATE:	09/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Cherry Aguila		TIME COMPLETED:	04:10 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	On 09/19/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Care Celine. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 11:30am, LPA Cho was greeted and allowed entry by Staff #1 (S1). Per the Facility Personnel Report Summary, S1 was not on the roster. S1 indicated that S1 was shadowing for training purposes. S1 informed Staff Remedios Manuel David who then greeted LPA and completed the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted throughout the facility. The Complaint Poster (PUB475) met the Department's size regulation. The facility is licensed for six non-ambulatory residents and has a hospice waiver for six. There are currently five residents living in the facility of which five are receiving hospice care. The Administrator's Certificate for Cherry Aguila expires on 11/11/2022. Around 11:43am, LPA Cho conducted a tour of the physical plant. Administrator (Admin) Cherry Aguila was returning from a grocery trip and arrived at the facility around 11:50am. LPA Cho immediately discussed the absence of S1's criminal record clearance. Admin was consulted the importance of having S1's fingerprint cleared prior to employment. Per Staff #2 (S2), S1 began shadowing on 09/19/2022 at 6:30am. At 11:56am, LPA observed S1 leaving the facility under the Admin's instruction. LPA reinitiated the tour with Admin Aguila. The two story home consists of five resident bedrooms and two resident bathrooms. There are two staff bedrooms on the second floor and one staff bathroom. The facility also has a living room, dining area, receiving area, kitchen, and an attached two car garage with a laundry area. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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 09/19/2022 03:55 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARE CELINE	FACILITY NUMBER: 306005457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

87355 Criminal Recrod Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, one out of two staff were not fingerprint cleared prior to employment which poses an immediate Health, Safety, or Personal Rights risk to persons in care. CIVIL PENALTY ASSESSED.
	POC Due Date: 09/20/2022
	Plan of Correction
1 2 3 4	Administrator agrees to obtain a Califormia clearance for all prospective staff prior to employment and to submit a fingerprint clearance of S1 by POC due date to LPA via email.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC809 (FAS) - (06/04)

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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: CARE CELINE	FACILITY NUMBER: 306005457
	VISIT DATE: 09/19/2022

NARRATIVE

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LPA tested the hot water temperature in the resident bathrooms and the temperature measured at 122.3 degrees Fahrenheit in the Bathroom #1 and 122.5 degrees Fahrenheit in Bathroom #2. The water temperature was readjusted during the visit.

LPA Cho inspected the kitchen along with Admin. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The two fire extinguishers were charged and inspected on 07/08/2021. Admin stated two fire extinguishers will be purchased. The smoke/carbon monoxide detectors and auditory devices were tested and operational except the smoke detector on the second floor hallway as it was missing a cover. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds with the Admin and observed a three tier fountain with small amount of water. There was a locked shed that stored cleaning solutions. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and two out of three exit gates were self-closing and self-latching. One out of three exit gates was missing a latch and did not close properly. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for and Residential Care Facilities for the Elderly (LIC610E). Facility has back-up emergency food and water supply. The First Aid Kit met all the required components except a first aid manual, and the facility had sufficient PPEs.

LPA consulted the following: to repair the side gate latch and smoke detector on the second floor, to install an auditory device on the exit door in the backyard, and to obtain two fire extinguishers and a current edition of a first aid manual. LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations, therefore an immediate civil penalty is assessed. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Administrator Cherry Aguila, and a copy of this report (LIC809, LIC809-C, LIC809-D, Civil Penalty Assessment LIC421, LIC9102s, and the appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC809 (FAS) - (06/04)

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