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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005530
Report Date: 04/25/2024
Date Signed: 04/25/2024 05:05:13 PM


Document Has Been Signed on 04/25/2024 05:05 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:VIVIDUS SENIOR LIVINGFACILITY NUMBER:
306005530
ADMINISTRATOR:SHARIFAN, BAABAKFACILITY TYPE:
740
ADDRESS:25572 MAXIMUS STTELEPHONE:
(949) 777-5369
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Baabak Sharifan- AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Jessica Cho, Edward Kim, and Faith La arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPAs were greeted and granted entry by Caregiver Edgardo Sevilla and explained the purpose of the visit. Administrator (Admin) Baabak Sharifan was advised of the visit by telephone and arrived on premise approximately 1:00pm.

The facility is licensed for 6 and maintains a hospice waiver of 2. As of today, the resident census is 6 of which 2 are ambulatory, 3 are non-ambulatory, and no residents are receiving hospice care. At or approximately 9:34am, LPAs conducted a tour of the physical plant accompanied by the caregivers, and the following were observed:

This is a single-story facility comprised of five resident bedrooms and two resident bathrooms. Common areas include the kitchen, two dining areas, living room, laundry room, and a two-car garage. LPAs observed signs of personal belongings in the garage evidenced by (2) beds, clothing items, and personal hygiene supplies. The resident bedrooms had all the required elements with ample lighting. The residents' bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the non-skid mats were in place. The hot water temperature measured within range at 105.2 and 106.3 degrees Fahrenheit. LPAs inspected the kitchen and the dining areas. Facility had adequate supply of two-day perishables and seven-day non-perishables but was lacking in quantity and variety of fruits to meet the two-day supply. LPAs observed during the visit groceries including fruits were dropped off at 2:33pm. LPAs observed 2 expired non-perishable food items in the pantry which were disposed during the visit. LPAs also observed the emergency food and water. Sharps were observed unsecured underneath the kitchen cabinet as well as the laundry detergent in the laundry room which were also corrected during the visit. The fire extinguishers were mounted, fully charged however was last serviced by the Fire Marshall on 12/30/2021.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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: VIVIDUS SENIOR LIVING
FACILITY NUMBER: 306005530
VISIT DATE: 04/25/2024
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The auditory devices, smoke detectors, carbon monoxide detectors were tested and in operating condition. LPAs toured the outside grounds. There were sufficient seating and shading for the residents, and the walkways were clear of hazards. One out of the two exit gates were not self-closing and self-latching.

LPAs reviewed six residents’ files. No pre-appraisals and re-appraisals were observed for four out of the six residents. One Physician's Report was not present and the second was not current. Interviews were conducted with six residents and two staff. The medications and the Medication Administration Records (MARs) were reviewed for six residents. No discrepancies noted. Staff files were not available for review at the time of inspection.

The following items were reviewed: Complaint Poster (PUB475) in the required size, food menu, activities, resident's rights, Emergency Disaster Plan (LIC610D), and the Infection Control Plan.

The following items were advised: to purchase or service the fire extinguishers annually, ensure toxins/sharps are secured, audit/organize/label the expiration dates of the pantry items, repair one exit gate to ensure it self-latches unassisted, to maintain, organize, the resident files and the required documents annually or as needed upon change of condition with respect to the Physician's Reports, Reappraisals, and to obtain a doctor's order for the half rails for Resident #1 (R1).

Based on LPAs' observations, one deficiency will be cited today as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. The remaining deficiencies will be addressed on the continuation inspection at a later date due to time constraints in addition to the review of staff files.

An exit interview was conducted with Administrator Baabak Sharifan, and a copy of this report along with the LIC9099C, LIC9099D, and the appeal rights 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: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 05:05 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: VIVIDUS SENIOR LIVING

FACILITY NUMBER: 306005530

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1-2)
87705 Care of persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: 1) Knives… and other items that could constitute a danger to the resident(s) (2) …. cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Based on LPAs’ observations, LPAs observed knives and laundry detergent unsecured in their respective cabinets which poses an immediate Health, Safety, and/or Personal Rights risk to persons in care.
Deficient Practice Statement
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Based on LPAs' observations, the licensee did not comply with the section cited above by having the knives and laundry detergent accessible and unsecured in their respective cabinets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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The sharps and the laundry detergent were placed in a secured area while the magnetic locks were repaired. Administrator stated that they will submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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