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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005554
Report Date: 07/14/2022
Date Signed: 07/14/2022 11:44:33 AM

Document Has Been Signed on 07/14/2022 11:44 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DEVOTED HEART CARE HOMES LLCFACILITY NUMBER:
306005554
ADMINISTRATOR:KEVIN CLARKFACILITY TYPE:
735
ADDRESS:26665 AVENIDA SHONTOTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 2DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Phone interview with Licensee Kevin Clark TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in the facility. Via phone LPA spoke with Licensee Kevin Clark; and stated the purpose of this visit.

At 8:41 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. LPA observed two clients in care and three staff members on the floor ( The third staff was the outgoing night staff). One client was later picked up by the day program. Per interview with Licensee, another client moved out and transferred to affiliated licensed facility effective July 1, 2022.

At 9:21 AM, LPA conducted a tour of the interior and exterior portion of the two level facility. Facility is licensed 4 ambulatory. On the upper floor are the three client rooms (Client 1 and two empty rooms). Rooms were provided with bed furniture, clean linens, storage cabinets, and table. The upper bathroom was provided with a bath tub, and water fixtures in good repair. Hot water was measured at 115 degrees Fahrenheit. In the lower level is another client's room which was provided with bed furniture lined with clean linens, a recliner and storage cabinet. Lower bathroom was provided with walk in shower area and water fixtures in good repair. Hot water was measured at 114 degrees Fahrenheit. LPA tested the hardwired smoke and carbon monoxide alarms and were observed to be operational. Fire extinguisher was mounted and charged. Locked medication cabinet contained client's medications, records, sharp kitchen items, and first aid kits. For the kitchen, facility met the minimum 2 day perishable and 7 day non-perishable food stock requirements. For the exterior portions, LPA observed self latching side gates, and patio furniture in good repair. After the tour, LPA reviewed the medications for Client 1 and Client 2. Administrator Kenneth Leonard certificate is valid until 1/6/2024.

For this visit, the following deficiencies were observed: At 9:22 AM, inside Client 1 room was an office chair with torn fabric on arm rest; and chair was leaning towards the left. At 9:36 AM, in the garage area converted as audiovisual or game room, the plastic storage cabinet that held cleaning supplies was in disrepair. Holes intended for padlocks were worn out; and doors can be opened without unlocking the locks.
(Continuation in Page 2)
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554
VISIT DATE: 07/14/2022
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Deficiencies had been observed, and citations had been issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted a phone exit interview with Licensee Kevin Clark. LPA read the report; reported the deficiencies observed and citations issued; explained the advisory notes and appeal rights. Licensee gave permission for staff to sign and receive the report. LPA left copies of the report, deficiency page, advisory notes, appeal rights, and regulations cited at the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 11:44 AM - It Cannot Be Edited


Created By: Albert Marin On 07/14/2022 at 10:44 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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility missed to maintain the facility in good repair at all times for the safety and well-being of clients. In Client 1's room, the office chair used by the client had a torn fabric arm rests, and the chair was leaning towards the left. This is a potential threat on the health and safety of the client in care.



POC Due Date: 07/28/2022
Plan of Correction
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Licensee agreed to replace the furniture; and provide proof of correction on or before 07/28/2022.

Note: LPA provided copy the Section 80087 for reference.
Type B
Section Cited
CCR
80087(g)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation facility missed to keep the disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. LPA observed that the doors of the stoage cabinets for cleaning supplies and disinfectants located in the garage but converted to a common audio visual or game area were closed but with opened padlock. The holes for the padlocks were worn out and can be easily accessed without opening the padlocks. This poses potential threat on the safety of the clients in care.
POC Due Date: 07/28/2022
Plan of Correction
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Licensee agreed to replace the furniture; and provide proof of correction on or before 07/28/2022.

Note: LPA provided copy the Section 80087 for reference.
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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
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