<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005663
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:50:19 PM

Document Has Been Signed on 09/01/2022 02:50 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:ALLIANCE SENIOR CAREFACILITY NUMBER:
306005663
ADMINISTRATOR:GACAD, EVELYNFACILITY TYPE:
740
ADDRESS:24362 APHENA AVETELEPHONE:
(714) 588-9228
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Evelyn Gacad TIME COMPLETED:
02:00 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) Albert Marin made an unannounced visit to this facility. LPA met with Administrator (AD) Evelyn Gacad, and stated the purpose of this visit.

On August 26, 2022, Community Care Licensing Division (CCLD) Orange Office received an incident report on Resident 1 who got out of the facility unattended. Resident was brought back to the facility without further incident.

For this visit, LPA Marin tour the interior and exterior portions of the facility. LPA observed five residents in their respective bedrooms and two care staff members on the floor. One resident is currently admitted in the hospital. LPA observed all auditory exit alarms installed in all exit doors were observed to be operational. Side exit doors were both self closing and self latching. Grounds were free of tripping hazards.

For this visit, deficiency was observed; citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Gacad. LPA discussed the deficiency, citation, immediate civil penalty, and appeal rights to AD. Copy of this report was left in the facility.



SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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 09/01/2022 02:50 PM - It Cannot Be Edited


Created By: Albert Marin On 09/01/2022 at 02:13 PM
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: ALLIANCE SENIOR CARE
FACILITY NUMBER: 306005663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited
CCR
87705(b)(2)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia... In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering.. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
AD requested immediate medical consult for Resident 1 to determine appropriateness in the facility. Threat reduced. As proof of correction AD will provide training to staff on residents that have wandering behavior. Proof of training wil lbe provided to CCLD on or before 9/22/22
8
9
10
11
12
13
14
Based on observation, file review and interviews, facility missed to provide safety measures to address the wandering behavior of the resident. Resident 1 was able to leave the facility without assistance. This posed immediate threat on the safety of the resident in care.
8
9
10
11
12
13
14
Immediate civil penalty was assessed.

Copy of the cited regulation was provided for full reference.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2