306005631-12-12-2024-22-AS-EBEY-DBW39Q-20241212170332

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005631
Report Date: 12/12/2024
Date Signed: 12/12/2024 05:03:50 PM

Document Has Been Signed on 12/12/2024 05:03 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:	BUENA PARK ELDER CARE		FACILITY NUMBER:	306005631
ADMINISTRATOR/ DIRECTOR:	SANTA ANA, OSVALDO		FACILITY TYPE:	740
ADDRESS:	6351 SAN RUBEN CIRCLE		TELEPHONE:	(562) 637-3392
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Runette Catibog		TIME VISIT/ INSPECTION 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	On December 12, 2024, Licensing Program Analysts (LPAs) Eboni Bentley, Edward Kim, and Licensing Program Manager (LPM) Lourdes Montoya conducted an unannounced visit for the purpose of conducting a required one-year annual visit using the CARE Inspection Tool. LPAs Bentley, Kim, and LPM Montoya were greeted, granted entry by staff, and explained the reason for the visit. Staff called the Administrator (AD) Runette Catibog via telephone who arrived a short time later and was present for the visit. AD Catibog has a current Administrator Certificate and a pending renewal for Osvaldo Santa Ana received April 14, 2024. This is a single-story building with attached garage. The facility has five bedrooms and two full bathrooms. Four bedrooms are occupied by residents and one bedroom occupied by staff. The facility is licensed for six (6) non-ambulatory residents, one (1) bedridden, with approved hospice waiver for six (6) residents. Currently, there are four (6) residents of which there are two (2) on hospice resident present during today’s visit. There were six residents present during the visit. At 9:15AM LPAs Bentley, Kim, and LPM Montoya conducted a tour of the physical plant accompanied by AD Catibog, and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the client's personal belongings were observed in residents’ closets. Additional bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperatures measured 115.5 and 116.4 degrees F. maintained in the bathrooms throughout the facility. All resident bedrooms were clean, well-organized, and had all the necessary items and storage space. The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the sink. Hazardous cleaning chemicals were found in a locked cabinet, under the sink. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed in the pantry near the stove. A fully charged fire extinguisher was near the pantry with a last service date of November 25, 2024. In the dining room, is a locked medication cabinet behind the table with medications and resident files.

Lourdes Montoya	TELEPHONE: (714) -705-6014
Eboni Bentley	TELEPHONE: 714-552-7883
	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BUENA PARK ELDER CARE	FACILITY NUMBER: 306005631
	VISIT DATE: 12/12/2024

NARRATIVE

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The garage was clean organized, and walkways were free of clutter and debris. A deep freezer with a supply of perishable items and a small, locked medication refrigerator for Hospice residents was observed. A washer and dryer were observed to be in working condition. LPA Bentley observed a first aid kit with all the required elements on a shelf.

There is a cabinet near the rear of the garage with additional hygiene supplies, cleaning items, and surgical face mask, and plenty boxes of adult diapers being stored in the cabinets and garage.

The backyard was clean and free of clutter and debris. The side exit gate was self-closing. A shaded patio area with tables and chairs observed. Two small storage sheds right next to each other was observed locked. Smoke detectors were tested and operational.

Facility has emergency food and water supply. A review of the Medication Records Administration (MAR) was conducted, and LPAS observed the records are in compliance.

A review of six residents (R1-R6) service files and four staff (S1-S5) personnel files revealed to be complete. Facility has liability insurance on file effective November 24, 2024

Licensing Program Analysts (LPAs) Eboni Bentley, Edward Kim, and Licensing Program Manager (LPM) Lourdes Montoya observed on-site Facility Sketch is inconsistent with Facility Sketch on file at Regional Office. LPAs and LPM will verify with original office records.

One deficiency was cited during today’s inspection visit. One Type B Violation was provided as four out of five burners were working and one was not operational.

An exit interview conducted and a copy of the report and appeal rights were provided to Designated Administrator Runette Catibog.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -705-6014
LICENSING EVALUATOR NAME: Eboni Bentley	TELEPHONE: 714-552-7883
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/12/2024 05:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BUENA PARK ELDER CARE	FACILITY NUMBER: 306005631
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as one out of five stove burners is not operational, which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Designated Administrator agreed to repair the stove burner by 12/20/2024 and will submit a POC via email to CCLD eboni.bentley@cdss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (714) -705-6014
Eboni Bentley	TELEPHONE: 714-552-7883
	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

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