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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005566
Report Date: 05/22/2024
Date Signed: 05/22/2024 11:35:26 AM


Document Has Been Signed on 05/22/2024 11:35 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:A1 RCFE @ DELPHINEFACILITY NUMBER:
306005566
ADMINISTRATOR:VILLARMINO, SHIRLEYFACILITY TYPE:
740
ADDRESS:923 HUGGINS AVETELEPHONE:
(714) 399-5040
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 5DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Maryann Ednlig
Shirley Villarmino		TIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Jorge Meza. LPA met with Staff Maryann Ednlig and explained the purpose of the inspection.

During the inspection LPA and Staff Ednlig conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a two-story home with four resident bedrooms, two bathrooms, and attached two-car garage on the first floor. The second story is used as staff quarters. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. The front patio has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.8-115.3 degrees F. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were observed to be fully charged with service tags dated December 12, 2023. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen cabinet. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked.

Administrator (AD) Shirley arrived at 9:00 a.m. to assist with the inspection. LPA reviewed three resident files and two staff files. Annual staff training completed did not contain eight hours of dementia care training, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care; a Deficiency was cited on today’s date. LPA interviewed three residents and two staff. (Cont. LIC809-C)

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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 3


Document Has Been Signed on 05/22/2024 11:35 AM - 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: A1 RCFE @ DELPHINE
FACILITY NUMBER: 306005566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AD admission, the licensee did not comply with the section cited above as the facility does not have at least one internet access device dedicated for resident use, which poses a potential personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Type B
Section Cited
HSC
1569.625(b)(2)
(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 section1569.626, 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
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Based on staff file review, the licensee did not comply with the section cited above as facility staff have not completed eight hours of dementia care training, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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AD stated staff training would be conducted immediately and proof submitted to LPA via email by POC 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: A1 RCFE @ DELPHINE
FACILITY NUMBER: 306005566
VISIT DATE: 05/22/2024
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Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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