306005520-10-18-2023-22-AS-DLMN-CWQPAH-20231018110847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005520
Report Date: 10/18/2023
Date Signed: 10/18/2023 11:09:30 AM

Document Has Been Signed on 10/18/2023 11:09 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BUENA VISTA HOME		FACILITY NUMBER:	306005520
ADMINISTRATOR:	TUASON, LIEZL		FACILITY TYPE:	734
ADDRESS:	17777 BUENA VISTA		TELEPHONE:	(714) 983-7277
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY: 5		CENSUS: 4	DATE:	10/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Liezl Tuason - Administration		TIME COMPLETED:	11:25 AM

NARRATIVE

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Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted an unannounced visit at Buena Vista Home (ARFPSHN) for the purpose of conducting a required annual visit. At 9:00am LPA was greeted and granted entry into facility by RN Aisa Guiling. Administrator Liezl Tuason, joined the inspection at approximately 9:50am.

The facility is a one-story home with five bedrooms, three bathrooms, kitchen, dining room, living room, laundry room, backyard, front yard, detached garage and basement. LPA observed residents participating in day program activities at the facility. Resident participate in table top games, reading, wheelchair swing, outings and getting fresh air in the front yard. Facility appears thoroughly clean, sanitary, organized, comfortable and accommodating for all residents. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 117.2 degrees Fahrenheit in bathroom three. Hot water measured at 97 degrees Fahrenheit in bathroom two. Hot water measured at 98 degrees Fahrenheit in bathrooms one and t. Administrator stated to LPA that their lease agreement prevents facility staff from adjusting the water heater. LPA waited approximately 45 minutes after the initial measurement to measure the water again. The water still measured below 105 degrees Fahrenheit. Administrator stated they will have the water heater serviced. A deficiency is being given on this day. LPA observed facility has emergency food and water supply. Medication for each resident is kept in locked drawers in their respective rooms. The yards have four shaded seating areas . Exit gates are unlocked and self latching. LPA reviewed two of the four residents files, each contained required documentation including updated exception requests.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted with Administrator Liezl Tuason and RN Aisa Guiling. A copy of this report and appeal rights were provided

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 10/18/2023 11:09 AM - It Cannot Be Edited

Created By: Dwayne L Mason On 10/18/2023 at 10:29 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BUENA VISTA HOME	FACILITY NUMBER: 306005520
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above as two of the three bathrooms had hot water temperatures below 105 degrees Fahrenheit which poses a potential safety risk to persons in care. Licensee stated to LPA that their lease agreement prevents facility staff from adjusting the water heater. LPA waited approximatley 45 minutes after the initial measurement to measure the water again. The water still measured below 105 degrees Fahrenheit.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee stated that they will get the water heater serviced and contact LPA by the POC due date of 10/27/2023 to schedule a followup visit for LPA to return to facility to test water temperature.

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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