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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005457
Report Date: 10/01/2024
Date Signed: 10/01/2024 09:18:41 AM


Document Has Been Signed on 10/01/2024 09:18 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 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: 3DATE:
10/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Cherry Aguila-Administrator TIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPAs) Jessica Cho and William Vanegas made an unannounced visit for the purpose of clearing the deficiencies cited during an annual inspection conducted on September 9, 2024 from 7:00am - 2:45pm.
  • Deficiency cited under Title 22 Regulations 87705 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). ---- Locking mechanisms were repaired during the visit on September 9, 2024.
  • Deficiency cited under Title 22 Regulation 1569.618 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.---- Cleared
  • Deficiency cited under Title 22 Regulation 87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.--- Cleared
  • Deficiency cited under Title 22 Regulation 1569.69 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: ---- Cleared
  • Deficiency cited under Title 22 Regulation 87457 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.--- Cleared
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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 2


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: 10/01/2024
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  • Deficiency cited under Title 22 Regulation 87458 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.---- Cleared
  • Deficiency cited under Title 22 Regulation 87458 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.---- Cleared
  • Deficiency cited under Title 22 Regulation 1569.695 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 --- Cleared
  • Deficiency cited under Title 22 Regulation 87705 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.---- Cleared
  • Technical Violations pertaining to posting of No-Smoking signs and replacing batteries --- Cleared
  • Technical Assistance pertaining to labeling pantry items. --- Cleared


All deficiencies and Technical Advisories have been cleared.

An exit interview was conducted with Administrator Cherry Aguila, and a copy of this report and the Letter of Deficiencies Citations Cleared were provided 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: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
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