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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005705
Report Date: 04/15/2024
Date Signed: 04/15/2024 05:43:06 PM

Document Has Been Signed on 04/15/2024 05:43 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:EDWARD BOARD AND CARE HOMEFACILITY NUMBER:
306005705
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, MARISAFACILITY TYPE:
735
ADDRESS:117 EDWARD AVE.TELEPHONE:
(714) 290-3809
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: 4DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Marisa HernandezTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Tea, Rose Ruppert and Licensing Program Manager (LPM) Alisa Ortiz conducted an unannounced visit for the Required One-Year Inspection. LPA Ruppert explained the purpose of today’s visit and was greeted and granted entry by Jeremiah Smith. LPAs and LPM met with Administrator Marisa Hernandez.

For today’s visit, LPAs observed a total of three of four clients in care and two staff members on duty.

LPAs observed the Administrator's Certificate which expires on March 31, 2025. LPA Tea observed the PUB475 “See Something Say Something” poster was located and posted in the den and was not the required 20" X 26" size.

LPA Tea and LPM Ortiz toured the interior and exterior portions of the facility with caregiver Jeremiah. The facility is a one level structure and is licensed for four ambulatory clients.

There are a total of four client bedrooms, of which all are private client rooms,and one private room for staff. LPA Tea and LPM Ortiz toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detectors and auditory exit alarms were tested and operational. There are a total of three restrooms of which one is for staff and two are for clients. Restrooms were observed to be missing handrails in both client showers. Toilets were operational, and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 116 - 119 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were located in hallway and were observed to be locked and inaccessible to clients in care. Fire extinguishers were charged, mounted and located in the hallway and kitchen.

LPAs and LPM observed the emergency disaster and evacuation plan, which is posted in the den. Facility had back-up emergency food and water supply, located in the hallway closet. LPA Tea observed that the First Aid Kit had all the required components. LPA Tea observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Tea observed patio furniture under shading, and the grounds were free of any hazards. There are two gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed.

For today's visit two Type A deficiencies, a technical violation and technical assistance citations were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Marisa Hernandez. A copy of this report was provided and explained.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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Document Has Been Signed on 04/15/2024 05:43 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 04/15/2024 at 05:09 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: EDWARD BOARD AND CARE HOME
FACILITY NUMBER: 306005705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs and LPM observation and file review the garage was converted to a staff bedroom. Facility sketch does not match. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Administrator will email LPA Ruppert with communication with the Orange County Fire Authority by April 16, 2024. Administrator will submit proof of fire clearance permitting room being utilized as staff quarters authorization to be utilized as such by May 7, 2024.
Deficiency Dismissed
Type A
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Tea's observation the licensee did not comply with the section cited above in two of three bathrooms] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Administrator will research prices and submit proof by emailing LPA Ruppert withing 24 hours. Administrator will submit proof of work completed by April 23, 2024.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024


LIC809 (FAS) - (06/04)
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