306005680-10-7-2022-22-AS-ETAA-CJYRLS-20221007130738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005680
Report Date: 10/07/2022
Date Signed: 10/07/2022 01:07:55 PM

Document Has Been Signed on 10/07/2022 01:07 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:	CARNELIAN VILLAS		FACILITY NUMBER:	306005680
ADMINISTRATOR:	STRUVE, JING		FACILITY TYPE:	740
ADDRESS:	1773 S. CARNELIAN STREET		TELEPHONE:	(714) 860-4490
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	6	CENSUS: 6	DATE:	10/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Richard Robles		TIME COMPLETED:	01:20 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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Administrator Cherie Wood was unable to make the inspection. The facility is a single-level structure licensed for six non-ambulatory with a hospice waiver for four. Four may be bedridden. This facility offers Residential Care for the Elderly/Dementia. At about 11:15 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 5 residents in care and a staff member on duty. LPA toured the interior and exterior portions of the facility. There were 6 resident rooms. The facility also had a staff room which is inaccessible to residents. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 115.5 degrees Fahrenheit. Fire alarms and carbon monoxide alarms were tested to be operational. For the exterior portion, furniture was in good repair; and grounds were free of tripping hazards. LPA did notice a ladder and some chairs that needed to be repair. LPA also noticed two bed frames. Staff stated they will be picked up today. Facility offers a 2-car garage which is used for storage with an operational washer/dryer and 2 refrigerators. LPA noticed medications in one of the refrigerators. LPA was informed that one of the refrigerators was not working. LPA informed staff that non-operational refrigerator needs to be discarded. Kitchen was in good repair. LPA noticed no locks for the medications. Staff could not find the lock. LPA made them aware of citation. LPA noticed locks for disinfectants and sharps needed to be replaced.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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: CARNELIAN VILLAS	FACILITY NUMBER: 306005680
	VISIT DATE: 10/07/2022

NARRATIVE

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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, one deficiency was noted in areas observed. One advisory was issued today.

LPA Tapia conducted an exit interview with staff and copy of this report along with appeal rights were explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 10/07/2022 01:07 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: CARNELIAN VILLAS	FACILITY NUMBER: 306005680
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by: The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 2 out of 2 counts which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Administrator will purchase a refrigerator for medication and will purchase a lock for centrally stored medications.

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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

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