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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005709
Report Date: 01/16/2024
Date Signed: 01/16/2024 12:58:26 PM

Document Has Been Signed on 01/16/2024 12:58 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:GENERATIONS OF ANAHEIM ASSISTED LIVING, INCFACILITY NUMBER:
306005709
ADMINISTRATOR:MANALAD, JOSELITOFACILITY TYPE:
735
ADDRESS:1941 E. CENTER STREETTELEPHONE:
(714) 533-3640
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 42CENSUS: 41DATE:
01/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Jordan Nguyen-Administrator AssistantTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240110140404. LPA was greeted and granted entry into the facility by Administrator Assistant (ADA) Jordan Nguyen and explained the reason for the visit.

During the course of the complaint investigation, it was reported via interviews by Staff 1 (S1) that Client's 1 (C1) bed was discovered to be broken on 12/25/23. Per S1 C1's new bed was replaced on 01/13/24, C1's bed was replaced approximately 19 days later.

Based on today's visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Wellness Coordinator (WC) and a copy was provided as well as Appeal Rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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 01/16/2024 12:58 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 01/16/2024 at 12:25 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: GENERATIONS OF ANAHEIM ASSISTED LIVING, INC
FACILITY NUMBER: 306005709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
01/17/2024
Section Cited
CCR
85088(c)(1)

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Fixtures, Furniture, Equipment and Supplies (c)The licensee shall ensure provision to each client of the following furniture...(1)An individual bed...maintained in good repair. This requirement is not met as evidence by: Based on interviews conducted and file review the facility did not have a bed in
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Per Administrator Assistant a new bed for C1 was delivered on 01/13/24.
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in good repair for C1. This poses an immediate risk to resident’s health and safety.
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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:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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