306005471-10-25-2024-22-AS-EKIM-DADVZ3-20241025165203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005471
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:52:11 PM

Document Has Been Signed on 10/25/2024 04:52 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:	A&M ASSISTED LIVING		FACILITY NUMBER:	306005471
ADMINISTRATOR/ DIRECTOR:	NATALIA SURGENT		FACILITY TYPE:	740
ADDRESS:	4461 PALOMA LANE		TELEPHONE:	(714) 366-1858
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	10/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:05 PM
MET WITH:	Assistant Administrator- Kevin Surgent		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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On October 25, 2024, at 1:05pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Daniela Usurelu. Assistant Administrator (AA) Kevin Surgent arrived to the facility around 1:15pm.

The facility is licensed to operate for five (5) nonambulatory resident of which one (1) may be bedridden and have a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with AA Surgent. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be clean and operational. The water temperature measured at 116.6 degrees F to 118.3 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, and emergency supplies were stored in the garage. Emergency water was stored in the staff office. The facility has one (1) fire extinguisher that was charged, mounted in the living area, and inspected on August 13, 2024.

Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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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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: A&M ASSISTED LIVING	FACILITY NUMBER: 306005471
	VISIT DATE: 10/25/2024

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) in the garage. All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-970-8331) remains available.

LPA Kim conducted an audit of six (6) resident files (R1-R6), staff files (S1-S3), and medication and medication administration review. LPA Kim conducted two (2) staff interviews and two (2) resident interviews.

A Deficiency was cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Assistant Administrator Kevin Surgent.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/25/2024 04:52 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: A&M ASSISTED LIVING	FACILITY NUMBER: 306005471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, LPA observed the back right burner of the stove was not turning on correctly. The licensee did not comply with the section cited above. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee states they will send a copy a purchase of the new oven/stove and evidence of it working to CCLD via email to edward.kim@dss.ca.gov by POC due date November 8, 2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC809 (FAS) - (06/04)

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