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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005726
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:51:59 PM


Document Has Been Signed on 06/14/2024 03:51 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:TRADITIONS AT STACEY LEEFACILITY NUMBER:
306005726
ADMINISTRATOR:DE LOS REYES, LORDELEFACILITY TYPE:
740
ADDRESS:5105 EAST STACEY LEE LANETELEPHONE:
(714) 769-5858
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 6DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Maricel NeumannTIME COMPLETED:
04:00 PM
NARRATIVE
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On June 14, 2024 at 8:20am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Caregiver Maricel Neumann and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory of which one may be bedridden and have a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, five (5) bathrooms, swimming pool, living room, dining room, kitchen, attached 3-car garage, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with Caregiver Neumann. There are no obstructions on the premises. Swimming pool is enclosed by a fence that is found to be within Title 22 regulations. The swimming pool fence is self-closing and self-latching. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 113.0 degrees and 115.3 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

The facility has two (2) fire extinguishers that are charged and they were all serviced on August 4, 2023. Smoke detectors and carbon monoxide detectors were operable. A working telephone (714-602-7673) remains available.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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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: TRADITIONS AT STACEY LEE
FACILITY NUMBER: 306005726
VISIT DATE: 06/14/2024
NARRATIVE
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LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, and supplies are stored in the garage. First Aid Kit contained all the necessary elements.

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA conducted an audit of resident files (R1-R6), staff files (S1-S3. and medication and medication administration review were in order and complete. LPA Kim conducted resident interviews and staff interviews.

Deficiencies were cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of this report was provided to Caregiver Maricel Neuman.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2024 03:51 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: TRADITIONS AT STACEY LEE
FACILITY NUMBER: 306005726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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. LPA observed hoses in the backyard and next to the air conditioning unit left out, and bricks, pipes, and metal items lying out next to the air conditioning unit. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee states they will throw away all items and buy a hose rack for each hose with a proof of POC with photos to CCLD via email to edward.kim@dss.ca.gov by June 21, 2024.
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed and interviewed S2 that the licensee did not notify Department of Social Services they would be gone for 10 days and who they designated as administrator. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee states they will send a completed LIC 308 to CCLD via email to edward.kim@dss.ca.gov by June 19, 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: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 06/14/2024 03:51 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: TRADITIONS AT STACEY LEE
FACILITY NUMBER: 306005726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed the record review S1-S3 did not the 2024 training verification available at the time of visit. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee states they will provide a copy of all staff training hours for 2024 to CCLD via email to edward.kim@dss.ca.gov by June 21, 2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed record review of the emergency fire/safety drills not being filled out.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee will conduct a fire/safety emergency drill and provide a copy of when the drill happened and who was trained to CCLD via email to edward.kim@dss.ca.gov by June 21, 2024. Licensee states they will conduct and keep record of drills quarterly.
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: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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