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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 08/29/2022
Date Signed: 08/29/2022 12:34:10 PM


Document Has Been Signed on 08/29/2022 12:34 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:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:HUNDLEY, SHANNONFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 11DATE:
08/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Lakshmi JonnadaTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to the facility in conjunction with complaint visit 22-AS-20220823143206. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the complaint visit, LPA observed the following: Facility does not have a register of residents. Facility was advised verbally to maintain a register/ roster of residents during case management visit on 08/23/2022. During the tour of the kitchen, LPA observed unsecured knives in the kitchen. During review of records for complaint, LPA observed there was no incident report submitted for Resident 1's (R1) hospitalization and hip fracture. Administrator indicates being advised by management to not forward an incident report to Licensing for the incident. Administrator provided the report to LPA during the visit.




Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy will be emailed as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/29/2022 12:34 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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306005773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2022
Section Cited

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Each licensee shall furnish to the licensing agency such reports.. as the following: A written report shall be submitted to the licensing agency.. within seven days...
Any serious injury.. while the resident is under facility supervision. This req is not being met as evidenced by:
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Based on interview and record review, Licensee failed to ensure R1's hospital admission and broken hip were reported to Licensing. This poses a potential health and safety risk to residents in care.
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Type B
09/05/2022
Section Cited

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The licensee shall ensure that a current register of all residents.. is maintained and contains the following updated information: (1) The resident's name and ambulatory status..(2) Information on the resident's attending physician (3)Information on the resident's responsible person. This req is not being met as evidenced by:
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Based on observation and interview, Licensee failed to ensure a register of residents is maintained at the facility. This poses a potential health and safety risk to residents in care.
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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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/29/2022 12:34 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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306005773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2022
Section Cited

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The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This poses an immediate health and safety risk to residents in care.
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Based on observation, Licensee failed to ensure knives are kept inaccessible to residents in care. LPA observed unsecured knives in the kitchen. This poses an immediate health and safety risk to residents in care.
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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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3