<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005599
Report Date: 11/21/2022
Date Signed: 11/21/2022 01:32:19 PM


Document Has Been Signed on 11/21/2022 01:32 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:A1 ELDER CAREFACILITY NUMBER:
306005599
ADMINISTRATOR:SHAH, BINDIFACILITY TYPE:
740
ADDRESS:2538 E LARKSTONE DRIVE #ATELEPHONE:
(949) 929-5318
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 5DATE:
11/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Bindi ShahTIME COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman along with Code Compliance Supervisor Rafael Perez, and Code Compliance Officers Ines Guzman, Antonio Olivos, and Adam Davis conducted an unannounced case management visit in conjunction with complaint visit 2-AS-20221115083100. LPA and Code Compliance were greeted and granted entry into the facility by Administrator Bindi Shah and explained the reason for the visit. Licensee Jitendra Shah arrived during the visit.

During the course of the complaint visit, it was determined through interview with Administrator that Licensee did not notify Community Care Licensing of intent to perform construction in order to alter Resident 1's (R1) room by building a wall in the center of room. The purpose of the construction was to make two private rooms instead of one shared room. LPA along with City of Orange Code Compliance Officers observed the alteration currently in place.







Based on the observations made during today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator and a copy will be provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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 2


Document Has Been Signed on 11/21/2022 01:32 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: A1 ELDER CARE
FACILITY NUMBER: 306005599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2022
Section Cited

1
2
3
4
5
6
7
Each licensee shall furnish to the licensing agency such reports as the Department may require..Any incident which threatens the welfare, safety or health of any resident...This requirement is not being met as evidenced by:
8
9
10
11
12
13
14
Based on interviews conducted, Licensee failed to notify Community Care Licensing of intent to perform construction to alter a room. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2