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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005599
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:08:32 PM


Document Has Been Signed on 12/08/2022 04:08 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: DATE:
12/08/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Gloria Sandoval and Jitendra ShahTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety visit in conjunction with a Plan of Correction visit. LPA was greeted and granted entry into the facility by Caregiver Gloria Sandoval and explained the reason for the visit.

During the visit, LPA toured the facility and observed the split resident room referenced in complaint #22-AS-20221115083100 and observed two residents are residing in the split room. On 11/21/2022, Licensee was cited for altering the room without a permit and LPA conducted a visit with City of Orange Code Enforcement. Licensee and Administrator participated in a phone call, same day, with LPA Lyman and LPM Alisa Ortiz regarding the resident residing in the room during that visit. Per Code Enforcement, Licensee and Administrator were advised no residents were to be residing in the room until the room was permitted. During today's visit, LPA Lyman spoke with Licensee Shah who stated he had submitted the paperwork to the city and was waiting for response. Licensee stated intent to go down to Code Enforcement to get an update. LPA reiterated no residents were to be residing in the room until permitted. Licensee ended the call.
LPA made multiple attempts to contact Administrator and received no response. Licensee to forward a copy of resident roster to LPA by close of business Friday, December 9, 2022.


Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Licensee 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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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 12/08/2022 04:08 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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2022
Section Cited

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not being met as evidenced by:
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Based on observation, Licensee altered a resident room off the floor plan approved by fire authority. Fire clearance is granted according to floor plan at time of inspection. Licensee has two residents residing in the altered room. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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Type B
12/22/2022
Section Cited

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All facilities shall have a qualified and currently certified administrator.. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible...This requirement is not being met as evidenced by:
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Based on observation, Licensee failed to ensure a back-up administrator is available at the facility. During the visit, Administrator is unavailable and did not return LPA's calls. However, Administrator communicated to caregiver via phone calls. This poses a potential health and safety risk to residents in care,
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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