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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 12/05/2022
Date Signed: 12/05/2022 02:07:38 PM


Document Has Been Signed on 12/05/2022 02:07 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 & INLAND A/SC, 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: 10DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Lily RamosTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Lily Ramos and explained the reason for the visit.
At 11:37 AM, LPAs toured the facility with Caregiver Ramos. Facility has 10 residents present during today's visit. Facility has covid precaution signage outside the facility. Facility screens all visitors to the facility and LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility has covid precaution postings inside facility as well. LPAs observed residents relaxing in the facility and eating lunch. Facility appears clean and sanitary. Smoke detectors/ carbon monoxide detectors tested operational during today's visit. At 11:40 AM LPAs observed an unsecured drug disposal bottle in the office. LPAs toured the kitchen and observed ample food supply as well as operational appliances. At 11:42 AM LPAs observed unlocked knives in an unlocked cupboard in the kitchen. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. First aid kit has all required items including scissors. LPAs observed ample emergency food, water, and supplies. LPAs toured the outside grounds and observed the shaded outside visitation area. At 11:54 AM LPAs observed the left wing exit gate was locked and inaccessible, the gate is locked from the outside. At 11:56 AM LPAs toured the storage room and LPAs observed unlocked bleach and laundry detergent on top of the laundry washing machine. Residents participate in activities such as exercise/ walking. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPAs reviewed select resident files during the visit and all files have updated emergency information.
LPAs consulted with Caregiver regarding the importance ensuring all facility restrooms have hand washing signs posted.
Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
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 12/05/2022 02:07 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 & INLAND A/SC, 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: 12/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
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 met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed unsecured knives, laundry detergent, bleach bottle and a drug disposal bottle (photos), which poses an immediate health and safety risk to persons in care. CIVIL PENALTY ASSESSED
POC Due Date: 12/06/2022
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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. LPAs observed the left wing exit gate is locked and inacessible, the gate is locked from outside which poses an immediate health and safety risk to persons in care.
CIVIL PENALTY ASSESSED
POC Due Date: 12/06/2022
Plan of Correction
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Licensee to remove lock and forward proof to LPA.

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: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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