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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005607
Report Date: 02/02/2024
Date Signed: 02/02/2024 10:44:08 AM


Document Has Been Signed on 02/02/2024 10:44 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:CANADIAN MANORFACILITY NUMBER:
306005607
ADMINISTRATOR:MCKEEVER, MARIAFACILITY TYPE:
740
ADDRESS:3159 CANADIAN DRTELEPHONE:
(562) 207-7216
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 4DATE:
02/02/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mercy Falco
Johnny Pimentel		TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management inspection for the purpose of conducting health and safety checks. LPA met with Staff Mercy Falco and Johnny Pimentel and explained the purpose of the inspection. Acting Administrator (AAD) Rosendo Miranda arrived at 9:30 a.m. AAD has an Administrator certificate with expiration date 2/02/24.

During the inspection, LPA conducted a tour of the inside and outside of the facility. The facility is a single-story home with five bedrooms, three and a half bathrooms, living room, kitchen, dining area, and attached two-car garage. LPA observed resident bedrooms had the required furnishings. LPA observed resident beds had linens and blankets. An extra supply of linen and bedding was observed in the hallway closet. Water temperature tested between 111.2-120.1 degrees F. Bathroom faucets and toilets were operational. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food, and residents were observed having breakfast. Appliances, including: gas stove, microwave, refrigerator, laundry washer and dryer were inspected and observed to be operable. Smoke detectors and carbon monoxide detectors tested operational. Toxic chemicals, including Clorox and disinfectants, were observed to be unlocked and accessible to residents in the kitchen and one resident bathroom; a Deficiency was cited on today’s date. Medication closet was also observed to be unlocked and accessible to residents; a second Deficiency was cited on today’s date. Fire extinguishers were charged, mounted, and located in the kitchen and hallway of the facility, with service tags dated 10/04/23. Facility has a shaded seating area in the backyard and no obstacles or hazards were observed.

Based on observations made during today’s inspection, two 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 and appeal rights was provided to the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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 2


Document Has Been Signed on 02/02/2024 10:44 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: CANADIAN MANOR
FACILITY NUMBER: 306005607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed medication closet to be unlocked and accessible, which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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Staff immediately locked the medication closet door. Licensee to conduct staff training regarding centrally stored medication to ensure it is safe, locked, and inaccessible to persons in care. Licensee to provide LPA with proof of training via email by POC date.
Type A
Section Cited
CCR
87309(a)
Disinfectants, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Disinfectants and cleaning solutions were observed to be unlocked and accessible to residents in the kitchen and one resident bathroom, which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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Staff obtained a lock and key and locked all toxic chemicals during inspection. Licensee to provide staff training regarding safe storage and inaccessibility of all and any toxic chemicals. Licensee will provide LPA with proof of training 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: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2