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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005608
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:03:50 PM

Document Has Been Signed on 06/12/2024 12:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TCT HOMES / PACIFICFACILITY NUMBER:
306005608
ADMINISTRATOR/
DIRECTOR:		ANTHONY AUFACILITY TYPE:
735
ADDRESS:9212 PACIFIC AVETELEPHONE:
(714) 827-2156
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Augustine Au, Asst. AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Jim Fernandez, House Manager. During today’s visit, LPA met with Augustine Au, Assistant Administrator.

The facility is a Level 4i, six bedroom, single story building with an approved fire clearance of six ambulatory clients. The facility currently has a census of five clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in three of three resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 116.0 and 127.9 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on July 26, 2023. The facility’s last fire drill was conducted on June 5, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA reviewed three of six staff training and fingerprint records. LPA conducted a complete review of client records. Client P&I records were reviewed. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 29, 2024.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations (see LIC 809-D). An exit interview was conducted with Augustine Au, Assistant Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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Document Has Been Signed on 06/12/2024 12:03 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 06/12/2024 at 11:45 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TCT HOMES / PACIFIC
FACILITY NUMBER: 306005608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst's (LPA) observation the licensee did not comply with the section cited above in two of three client bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Assistant Administrator Augustine Au will contact a plumber to inspect water heater and plumbing to ensure all bathrooms are within the temperature range.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review the licensee did not comply with the section cited above in five of five client files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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Assistant Administrator (AD) Augustine Au will mail Title 22 Admission Agreements to Power of Attorneys (POA) to review and sign documents. Once signed, Asst. AD will scan signed documents to LPA.
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 Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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