<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005478
Report Date: 03/02/2023
Date Signed: 03/02/2023 05:23:59 PM


Document Has Been Signed on 03/02/2023 05:23 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:SAINT BENEDICT CARE LLCFACILITY NUMBER:
306005478
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:8925 CANARY AVENUETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
03/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:48 PM
MET WITH:Uldarico "Rico" Almiranez, Licensee/AdministratorTIME COMPLETED:
05:25 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 today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a Case Management- Deficiencies visit in conjunction with delivery of Amended report for the following complaint control #s: 22-AS-20211012143927 and 22-AS-20220829124546.

On today's date, LPA Quiroz arrived to the facility and was greeted, COVID-19 screened and met with Caregiver Kristine Guevarra. Caregiver Kristine Guevarra called Licensee/Administrator (L/AD) Uldarico Almiranez via telephone and LPA Quiroz discussed purpose of today's visit via telephone. (L/AD) Almiranez arrived during today's visit.

During the course of the investigation of Complaint Control #22-AS-20220829124546. the following deficiency was observed: California Code of Regulations (CCR)-87217 (d)(3): Safeguards for Resident Cash, Personal Property, and Valuables (d) Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:(3)become substitute payee for any payments made to any persons.
During today's visit, LPA Quiroz reviewed hand written document dated 1/31/2022 indicating Resident 1 (R1) is handing over disability benefits to facility effective 10/2021. This was verified with L/AD Almiranez who indicated agreeing with the above.

Copy of CCR-87217: Safeguards for Resident Cash, Personal Property, and Valuables was printed and coy was provided to (L/AD) Almiranez.

Today's report was reviewed with (L/AD) Almiranez and a copy of this report, LIC 809-D, LIC 811- Confidential name and Appeal Rights were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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


Document Has Been Signed on 03/02/2023 05:23 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: SAINT BENEDICT CARE LLC
FACILITY NUMBER: 306005478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2023
Section Cited

1
2
3
4
5
6
7
(CCR)-87217(d)(3):Safeguards for Resident Cash, Personal Property, and Valuables (d) Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:(3)become substitute payee for any payments made to any persons. This requirement is not met as evidenced by:
CONT
1
2
3
4
5
6
7
R1 is no longer residing at Saint Benedict Care LLC. Saint Benedict Care LLC is no longer the payee for R1. R1 is his own payee. L/AD Almiranez will read and understand CCR 87217 and provide proof of understanding to CCLD by 3/6/2023.
8
9
10
11
12
13
14
On 1/31/2022 L/AD Uldarico Almiranez had Resident 1(R1) sign a hand written letter to change social security benefits from (R1) to facility representative. This was verified with (L/AD)Almiranez indicating "To make sure I got paid for his share of cost because if R1 got it he wouldn't pay his share CONT...
8
9
10
11
12
13
14
of cost to me." This poses a potential risk to residents in care.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2