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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:47:08 AM


Document Has Been Signed on 05/16/2023 11:47 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:JUNGE, PAMELAFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 14DATE:
05/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Pamela JungeTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced case management visit in conjunction with complaint visit 2-AS-20230502113714. LPAs were greeted and granted entry into the facility by Administrator Pamela Junge and explained the reason for the visit.

During the course of the complaint investigation, LPA observed facility administrator is locking up hygiene supplies such as gloves and wipes. Administrator admits staff have no accessibility to items without administrator being present at the facility. LPA observed no gloves/ wipes are present in any restrooms or resident rooms and staff have to go to the living room to access one box of gloves. LPA observed two boxes of gloves during a subsequent visit and observed gloves are still secured with a key. Administrator and Med Tech have a key to the supplies. LPA observed no wipes available for staff during initial visit and one box in the common area on a subsequent visit. Interviews during the complaint investigation indicated four out of four staff state they are being denied access to the hygiene items and at times have had to work without the items. One resident interviewed state Caregivers have assisted without gloves. Additionally, LPA observed facility administrator has locked the emergency water supply making it inaccessible to residents and staff. During a subsequent visit, facility removed the lock but secured the water with a zip tie. Facility kitchen is under construction and there is currently no running water in kitchen. Administrator stated that residents have access to restroom water taps. LPA observed only a half gallon of water accessible to residents in kitchen during initial visit. Later on during the visit, additional water was delivered to the facility. Seven out of eight witnesses interviewed stated snacks are being restricted. LPA consulted with Administrator on regulatory requirements to ensure residents and staff have access to basic amenities.


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 Administrator and a copy was emailed to Administrator 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: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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 05/16/2023 11:47 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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87464(f)(1)

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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to provide a written plan outlining how access to hygiene products will be provided to staff. Licensee to forward plan by POC due date.
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Based on interview and observation, Licensee failed to ensure care is being provided to residents in care. Facility hygiene items are being restricted to staff thus preventing staff from providing sanitary and healthful care to residents. This poses an immediate health and safety risk to residents in care.
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Type B
05/30/2023
Section Cited
HSC1569.269(a)(8)

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Residents of residential care facilities for the elderly shall have all of the following rights: To make choices concerning their daily life in the facility. This requirement is not being met as evidenced by:
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Licensee to provide a written statement of understanding regarding resident rights and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure residents have the right to make choices in the facility. Facility has secured drinking water as the facility's kitchen is under construction limiting resident's choice for water. During the initial visit there was only a half gallon of water for residents. 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: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/16/2023 11:47 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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87405(a)(1)

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The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not being met as evidenced by:
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Licensee to review administrator qualifications and submit a statement of understanding of the regulation to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure administrator is qualified to provide care and supervision to residents in care. Administrator admits limiting access to basic amenities for residents.This poses an immediate health and safety risk to residents in care.
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Type B
05/30/2023
Section Cited
CCR87555(b)(3)

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The following food service requirements shall apply:
Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement is not being met as evidenced by:
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Licensee to forward a copy of a snack schedule to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure residents are being provided snacks. This poses a potential health and personal rights 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: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3