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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 12/07/2021
Date Signed: 12/07/2021 03:14:44 PM

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:REHBEIN, ERINFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 6DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Erin RehbeinTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch 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. Administrator Erin Rehbein arrived during the visit.
At 1:15 PM, LPAs toured the facility with Administrator Rehbein. Facility has six residents in care during today's visit, with two residents on hospice care. LPA observed residents relaxing in the facility. All residents appeared well taken care of. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPAs observed the screening station in the entrance of the facility. Facility screens all visitors to the facility and documents. Facility has covid precaution postings as well as all required department postings. LPAs toured the kitchen and observed the food supply. Facility has completed the mitigation plan and plan has been approved. LPAs observed emergency food and water as well as the first aid kit which contained all required items. LPAs toured the outside grounds and observed the outside visitation area. At 1:20 PM, LPAs observed unsecured cleaning supplies in the unlocked storage area as well as the exit gate is secured with a padlock. At 1:25 PM, LPAs toured the back side of the facility and observed the second exit gate is secured with a thick string. LPAs observed unsecured bleach, Lysol, and cleaner unsecured as well in the back area. At 1:35 PM, LPAs observed two different drawers in the kitchen contained unsecured knives. Residents participate in activities such as exercise and games. LPAs observed the locked medication storage area. Facility has ample supple of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files which contained all required documentation including emergency information and updated physician reports.
LPA consulted with Administrator regarding the importance of taking staff and resident temperatures daily and documenting as well as maintaining an adequate supply of emergency water on-site.
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. CONTINUED ON LIC 809C DATED 12/07/2021.



SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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
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
VISIT DATE: 12/07/2021
NARRATIVE
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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: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 12/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 being met as evidenced by:


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 both exit gates are secured. One gate is secured with a padlock and one gate is secured with a thick string. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
POC Due Date: 12/08/2021
Plan of Correction
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Licensee removed lock and string during visit.
Type A
Section Cited
CCR
87705(f)(2)
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:


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 cleaning supplies in the unlocked storage area, two drawers of unsecured knives, and unsecured bleach, Lysol, and cleaning spray unsecured outside. This poses an immediate health and safety risk to persons in care.
POC Due Date: 12/08/2021
Plan of Correction
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Licensee to secure all noted items and forward proof to LPA by POC due date.
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: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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