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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 10/03/2022
Date Signed: 10/03/2022 09:47:35 AM


Document Has Been Signed on 10/03/2022 09:47 AM - 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:JONNADA, LAKSHMIFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 13DATE:
10/03/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lilly RamosTIME COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 09/08/2022. LPA was greeted and granted entry into the facility by Caregiver Lilly Ramos and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87468.1(a) pertaining to Personal Rights has NOT been cleared. Licensee did not submit proof of correction. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ASSESSED.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. LPA observed facility has cleaned most of the cupboards after extermination. LPA did not observe any cockroaches. Licensee has complied with the terms of the POC.

LPA advised facility through an advisory note on 09/08/2022 to ensure all sharps and toxins are secured at all times. During the visit, LPA observed unsecured sharps in the kitchen as well as unsecured cleaning supplies such as bleach, oven cleaner and raid (photos). During the visit, LPA observed facility food supply. Food supply is low. Facility has no fresh fruit and 3 packages of meat in the freezer.


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: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
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 2


Document Has Been Signed on 10/03/2022 09:47 AM - 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: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
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 requirement is not being met as evidenced by:
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Based on observation, Licensee did not comply with the section cited above. During the visit, LPA observed unsecured knives in an unlocked kitchen cabinet as well as unsecured cleaning supplies (photos). This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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Type B
10/10/2022
Section Cited

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Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity, as specified in Section 87555, General Food Service Requirements. This requirement is not being met as evidenced by:
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Based on observation, Licensee did not comply with the section cited above. LPA observed food supply is low with no fresh fruit available and three packages of meat in the freezer. 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: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2