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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005527
Report Date:
08/08/2024
Date Signed:
08/08/2024 05:25:01 PM
Document Has Been Signed on
08/08/2024 05:25 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:
AGAPE SENIOR HOMES LLC
FACILITY NUMBER:
306005527
ADMINISTRATOR:
FISCHER, LONNIE
FACILITY TYPE:
740
ADDRESS:
11442 NEWPORT AVE
TELEPHONE:
(714) 393-2308
CITY:
SANTA ANA
STATE:
CA
ZIP CODE:
92705
CAPACITY:
6
CENSUS:
5
DATE:
08/08/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Lonnie Fischer, Administrator
TIME COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the inspection. Administrator Lonnie Fischer was notified via telephone and arrived later to assist with the visit.
During the inspection, LPA accompanied by facility staff conducted a tour of the physical plant and observed the following: The facility is a one-story home. There are five private bedrooms and five shared bathrooms including multiple en-suite bathrooms, in addition to the facility's common living areas. All resident bedrooms have the required furnishing, bathrooms are equipped with grab bars and slip mats. LPA observed all beds have linens and blankets. One resident not admitted on hospice is observed to have full bed rails which were substituted for half rails during the visit. No physician orders for these could be located.
The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently five residents admitted to the facility with three residents on hospice. At the time of the visit, no granted hospice waiver was found on file. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within the required range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire drills are not conducted quarterly. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Smoke and carbon monoxide detectors tested operational. Two fire extinguishers present is observed to be fully charged however the proof of maintenance is dated April 2020 and outdated. Sharp items, cleaning supplies and medications were confirmed to be inaccessible throughout the physical plant.
CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2024
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
6
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:
AGAPE SENIOR HOMES LLC
FACILITY NUMBER:
306005527
VISIT DATE:
08/08/2024
NARRATIVE
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CONTINUED FROM FROM LIC809
The medication central storage was also observed to be secure and was reviewed for accuracy during the visit. LPA reviewed five resident files along with four staff files. Multiple physician reports are observed to be dating by over a year for residents with an indication of dementia. No documentation of annual training for 2024 is present on file.
Based on the observations made during today’s inspection, two type A and six type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility administrator who then had to leave and gave permission to caregiving staff to sign on his behalf. A copy of this report along with appeal rights was emailed to the licensee at the conclusion of the visit.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
08/08/2024 05:25 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:
AGAPE SENIOR HOMES LLC
FACILITY NUMBER:
306005527
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and review of the facility sketch, the licensee did not comply with the section cited above as one bedridden resident is observed to be located in a room that is not identified which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/09/2024
Plan of Correction
1
2
3
4
Licensee has scheduled an update of the fire clearance with the Fire Authority on Thursday August 15, 2024. Clarification on the location of the bedridden room and update to the facility sketch.
Type A
Section Cited
CCR
87633(a)(1)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and records reviewed, the licensee did not comply with the section cited above as no records of an approved hospice waiver for three residents could be located which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/09/2024
Plan of Correction
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2
3
4
Licensee will locate its previous application for a hospice waiver and resubmit it for approval by the Department by the plan of corrections due date.
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) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
08/08/2024 05:25 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:
AGAPE SENIOR HOMES LLC
FACILITY NUMBER:
306005527
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Plan of Operation
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1569.618(c)(3)
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.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed, the licensee did not comply with the section cited above in as one caregiver is observed to have CPR training expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/08/2024
Plan of Correction
1
2
3
4
Licensee will ensure all care staff are in possession of a current CPR training and provide proof of completion to LPA before the plan of corrections due date.
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) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
08/08/2024 05:25 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:
AGAPE SENIOR HOMES LLC
FACILITY NUMBER:
306005527
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff records reviewed, the licensee did not comply with the section cited above as continued annual training was not completed by staff in 2024, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/08/2024
Plan of Correction
1
2
3
4
Licensee is contracting with a new vendor after its previous vendor went out of business. Updated training and proof thereof will be conducted and provided to LPA before the plan of corrections due date.
Type B
Section Cited
HSC
1569.695(c)
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.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff interview and records reviewed, the licensee did not comply with the section cited above as no fire and emergency drills have been conducted in the 2024 calendar year. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/09/2024
Plan of Correction
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2
3
4
Licensee will schedule quarterly drills for the remainder of the year and conduct at least one drill within the next 30 days.
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) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2024
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
08/08/2024 05:25 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:
AGAPE SENIOR HOMES LLC
FACILITY NUMBER:
306005527
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation conducted during the facility visit, the licensee did not comply with the section cited above as one resident not admitted onto hospice was observed to use a bed equipped with full bed rails, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/08/2024
Plan of Correction
1
2
3
4
Bed rails were substituted with half rails during the visit. Licensee to obtain physician orders for half bed rails and provide them tho the Department before the plan of corrections due date.
Type B
Section Cited
CCR
87705(c)(5)
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.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed, the licensee did not comply with the section cited above as three out of five physician reports were observed to be dating by more than a year for residents with established dementia diagnoses. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/08/2024
Plan of Correction
1
2
3
4
Licensee has requested updates to the residents' physician reports and will provide the updated documents to the Department before the plan of corrections due date.
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) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
08/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/08/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6