306005726-5-17-2022-22-AS-ETAA-CEHVMH-20220517163334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005726
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:33:48 PM

Document Has Been Signed on 05/17/2022 04:33 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:	TRADITIONS AT STACEY LEE		FACILITY NUMBER:	306005726
ADMINISTRATOR:	DE LOS REYES, LORDELE		FACILITY TYPE:	740
ADDRESS:	5105 EAST STACEY LEE LANE		TELEPHONE:	(714) 769-5858
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 5	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Lordele De Los Reyes		TIME COMPLETED:	04:45 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 Analysts (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Jicel Pulvera and stated the purpose of this visit. Administrator Lordele De Los Reyes arrived during the visit at 2:10 PM and provided assistance. The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden and a hospice waiver for four. This facility is a Residential Care Facility for the Elderly. At about 1:50 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 clients in care and two staff members on the duty. LPA toured the interior and exterior portions of the facility. There was one shared client room, five client private rooms and one private staff room. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. LPA noticed in Bedroom (1) tools and medication were visible and staff immediately removed and locked. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 135.6 degrees Fahrenheit. Bathroom( 2) was observed to be in good repair and provided with grab bars and hot water was measured at 134.0 degrees Fahrenheit. Bathroom(3) was observed to be in good repair and provided with grab bars and hot water was measured at 135.8 degrees Fahrenheit. Bathroom (4) was observed to be in good repair and provided with grab bars and hot water was measured at 137.1 degrees Fahrenheit. Bathroom (5) was observed to be in good repair and provided with grab bars and hot water was measured at 133.5 degrees Fahrenheit. Bathrooms (3) and (5) were observed with exposed razors and staff immediately removed and locked the razors. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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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Document Has Been Signed on 05/17/2022 04:33 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: TRADITIONS AT STACEY LEE	FACILITY NUMBER: 306005726
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 5 out of 5 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the hot water tempeture is always maintained pursuant to regulation and submit to LPA by POC due date.

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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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: TRADITIONS AT STACEY LEE	FACILITY NUMBER: 306005726
	VISIT DATE: 05/17/2022

NARRATIVE

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Fire extinguishers were observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Facility has a 3 car garage and is used for storage, emergency supplies and PPE. Laundry room was in good repair. Kitchen was in good repair with medications kept locked. LPA noticed scissors and had staff removed and put them in a locked area. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPAs 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. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Lordele De Los Reyes and copy of this report was 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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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