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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005680
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:36:09 PM

Document Has Been Signed on 12/23/2024 12:36 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:CARNELIAN VILLASFACILITY NUMBER:
306005680
ADMINISTRATOR/
DIRECTOR:
STRUVE, JINGFACILITY TYPE:
740
ADDRESS:1773 S. CARNELIAN STREETTELEPHONE:
(714) 860-4490
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:11 AM
MET WITH:Richard RoblesTIME VISIT/
INSPECTION COMPLETED:
01:11 PM
NARRATIVE
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Licensing Program Analyst LPA Samer Haddadin conducted an announced visit for the purpose of completing an annual inspection. LPA was greeted and granted entry by staff member, Richard Robles. Administrator (AD) Cherrie Wood arrived shortly after.

The facility is a single level home and licensed for six non-ambulatory of which 4 may be bedridden with a hospice waiver for 4. At the time of visit, resident had 5 residents in care. This facility is a Residential Care Facility for the Elderly. The facility had 7 bedrooms and 8 restrooms in which 6 are used for resident and 1 bedroom and bathroom for staff members.

LPA toured the interior and exterior portions of the facility. Resident rooms were provided with furniture, chair, clean linen, adequate storage space, and kept free of tripping hazards. LPA observed over-the-counter medication in resident’s bedroom located in top drawer of nightstand. Hard wired smoke detectors, carbon monoxide and audible exit alarms were tested to be operational. LPA observed six screwdrivers, plier and a pair of scissors in the kitchen drawer and were not secured. LPA observed knifes and sharp were not locked nor secured due to a broken locked. Also, chemicals were found under the kitchen cabinet sink unlocked accessible to residents in care.

LPA toured the outside exterior and observed shaded area for residents. LPA noticed both emergency exits doors were obstructed by a trash can and a brick from the opposite side. LPA tried to exit from one and could not.

Bathrooms were observed not to be in good repair as three out of the 8-bathroom sinks were clogged and one bathroom did not have access to hot water due to thick rust on handle. Hot water was measured at 116.6 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. LPA checked fire extinguisher and it was in the green and was last purchased in December of 20204. (..CONTINUE 809C....)

Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096
DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680
VISIT DATE: 12/23/2024
NARRATIVE
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LPAs reviewed two clients’ files and no medication discrepancies were observed. LPAs reviewed two staff files with no discrepancies. All files of staff and residents contained all required documentation. LPA did not observe that the emergency drill was last conducted on April 11, 2024 and not current

Based on this on this visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of appeal rights and this report was provided to AD.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer HaddadinTELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2024 12:36 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: CARNELIAN VILLAS

FACILITY NUMBER: 306005680

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in leavining chemeclas under sink unsecured and unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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AD wil provide proof and E mail LPA a copy by due date
Section Cited
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in sharpes unlocked and screw drivers in kitchn un secured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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AD wil provide proof and E mail LPA a copy by due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2024 12:36 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: CARNELIAN VILLAS

FACILITY NUMBER: 306005680

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/23/2024
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
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Based on observation, the licensee did not comply with the section cited above by not maintaining the three cloged restroom sinks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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AD wil provide proof and E mail LPA a copy by due date
Section Cited
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in leaving medication in resident's room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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AD wil provide proof and E mail LPA a copy by due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024

LIC809 (FAS) - (06/04)
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