306005607-5-27-2022-22-AS-PVEZ-CETVX2-20220527164848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005607
Report Date: 05/27/2022
Date Signed: 05/27/2022 04:48:56 PM

Document Has Been Signed on 05/27/2022 04:48 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:	CANADIAN MANOR		FACILITY NUMBER:	306005607
ADMINISTRATOR:	MCKEEVER, MARIA		FACILITY TYPE:	740
ADDRESS:	3159 CANADIAN DR		TELEPHONE:	(562) 207-7216
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 5	DATE:	05/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Sean McKeever - Administrator		TIME COMPLETED:	05:00 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) Patricia Velazquez conducted an unannounced visit to Canadian Manor. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Valeria Yazmiler Rodriguez Yee. Caregiver Mara Alejandra Reyes Osua was also present. LPA Velazquez proceeded to call the Orange Regional Office to verify the criminal record clearance of both caregivers as they did not appear on the Facility Personnel Report Summary. Administrators (Admin) Sean and Kayla McKeever arrived later during the visit. The facility is licensed for 6 non-ambulatory residents. The facility also has a Hospice waiver for 6 residents. There are currently 5 residents living in the facility and there are 4 residents diagnosed with Dementia. At 2:37 PM LPA Velazquez conducted a tour of the physical plant along with Admin Sean McKeever. The 1 story home consists of 5 resident bedrooms with 4 bathrooms. The facility also has a living room, dining area, and kitchen. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 106.8 degrees Fahrenheit in the first bathroom, at 105.8 degrees Fahrenheit in the second bathroom, at 110.4 degrees Fahrenheit in the left sink and at 110.6 degrees Fahrenheit in the right sink of the 3rd bathroom which Administrator verified. LPA Velazquez inspected the kitchen along with Administrator Sean McKeever. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. LPA and Admin observed the knives and other sharps were stored an unlocked drawer in front of the kitchen sink which Admin verified. LPA and Admin observed a plastic bag containing medications in an unlocked kitchen drawer

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: CANADIAN MANOR	FACILITY NUMBER: 306005607
	VISIT DATE: 05/27/2022

NARRATIVE

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which Admin verified. LPA and Admin observed bleach and other cleaning supplies stored in an unlocked cabinet underneath the kitchen sink which Admin verified. LPA and Admin observed the resident medications stored in a closet were unlocked at the time of the inspection with a resident observed near the unlocked medications which Admin verified. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were unlocked and easily accessible to residents which Admin verified. There were several auditory alarms throughout the facility that were not in operating condition which Admin verified

LPA Velazquez along with Administrator Sean McKeever toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents but the umbrella had a large tear in one area which Admin verified. There were several items in the back yard such a shovel, garden tools, dolly, broken pieces of furniture, old walker, and a Hoyer lift which Admin verified. The exit gate did have a self-closing latch. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit and a resident medication review was not conducted.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. A civil penalty was also issued. Due to time constraints LPA Velazquez was not able to complete the visit and will return at a later date where further citations will be issued. An exit interview was conducted with Administrator Kayla McKeever and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2022 04:48 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: CANADIAN MANOR	FACILITY NUMBER: 306005607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. IMMEDIATE CIVIL PENALTY ISSUED
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 2 persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all individuals obtain a CA clearance or criminal record exemption prior to working in a licensed facility. Licensee to submit written proof of criminal record clearance for Staff #3 to LPA by POC due date as well as submit a written statement indicating how they intend to adhere to this regulation.

Type A

Section Cited

CCR

87465(h)(1)(C)

87465(h)(1)(C) Incidental Medical and Dental Care. The following requirements shall apply to medication which are centrally stored : Medications shall be centrally stored under the following circumstances: Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or the Departmeny to be a sfety hazard to others.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 areas of the facility where medications were found in an unlocked manner and easily accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all medications are centrally stored and locked at all times and submit written proof to LPA by POC due 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/27/2022 04:48 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: CANADIAN MANOR	FACILITY NUMBER: 306005607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)(2)

87705(f)(1)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with Dementia: (1) Knives, matches, firearms, tools, and other that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies, and disinfectants.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 4 out of 4 instances where the following items were unlocked and accessible to residents: knives and other sharp items, bleach and other cleaning supplies, and tools which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2022
	Plan of Correction
1 2 3 4	Licensee to ensure it adheres to this section of Title 22 at all times and submit a written statement how they intend to adhere to this section of Title 22 to LPA by POC due date.

Type A

Section Cited

CCR

87705(j)

87705(j) Care of Persons with Dementia. The licensee shall an auditory device or other staff alert to monitor exits, if exiting presents a hazard to any residents.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 4 out of 7 exit doors that were either missing or had an inoperable door alarm which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all exit doors have auditory alarms in operating condition and submit written proof to LPA by POC due 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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