306005631-12-2-2022-22-AS-JHAY-CLQPYR-20221202104423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005631
Report Date: 12/02/2022
Date Signed: 12/02/2022 10:44:29 AM

Document Has Been Signed on 12/02/2022 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:	BUENA PARK ELDER CARE		FACILITY NUMBER:	306005631
ADMINISTRATOR:	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	CENSUS: 5	DATE:	12/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Runette Catibog		TIME COMPLETED:	10:55 AM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA Haley was greeted, granted entry by staff, and explained the reason for the visit. Staff called the Administrator (AD) Runette Catibog via telephone who later arrived a short time later and was present for the visit. AD Catibog has a current Administrator Certificate that expires 10.26.23. There were five residents present during the visit.

At 8:45 AM LPA Haley began the tour of the facility with staff. Near the facility entrance there's a screening station with mask, sanitizer, temperature logs, and a temperature thermometer. Across from the screening station there's a closet for staff clothing and other miscellaneous items. Right next to the screening station there's a closet used to store pillows and a supply of adult diapers.

All resident bedrooms were clean, well organized, and had all the necessary items and storage space. Both resident bathrooms were clean and organized. Hot water temperature was measured at 116.2 degrees Fahrenheit in bathroom #1 and 115.5 degrees Fahrenheit in bathroom #2.

The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the sink. All burners on the stove were operational. Hazardous cleaning chemicals were locked 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 on the floor near the pantry. In the dining room, is a locked medication cabinet behind the table with medications and resident files.

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 refrigerator used to store hospice medication was observed. A washer and dryer was observed and plenty of Adult diapers. LPA Haley observed a first aid kit with all the required elements on a shelf.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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: BUENA PARK ELDER CARE	FACILITY NUMBER: 306005631
	VISIT DATE: 12/02/2022

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There's a cabinet near the rear of the garage with additional hygiene supplies, cleaning items, and surgical face mask. LPA Haley also observed additional facility items like wheelchairs, oxygen tanks, and plenty boxes of adult diapers being stored in the garage.

The backyard was clean and free of clutter and debris. The side exit gate was self closing and self latching. A shaded patio area with tables and chairs observed. 2 small storage sheds right next to each other was observed. In both of the sheds were some facility items that need to be disposed of (mattress, commode, walker, and 2 chairs) and some recyclable items were observed in each storage shed.

No bodies of water was observed. Smoke detectors tested operational.

No deficiencies will be cited during todays visit. An exit interview conducted and a copy of the report was provided to Administrator Runette Catibog.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

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