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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005777
Report Date:
02/13/2024
Date Signed:
02/13/2024 03:17:39 PM
Document Has Been Signed on
02/13/2024 03:17 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 COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
CARE JORDAN 2
FACILITY NUMBER:
306005777
ADMINISTRATOR:
LIMPIADO, GIDEON
FACILITY TYPE:
740
ADDRESS:
1615 KENT LANE
TELEPHONE:
(949) 612-7927
CITY:
NEWPORT BEACH
STATE:
CA
ZIP CODE:
92660
CAPACITY:
6
CENSUS:
5
DATE:
02/13/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Gideon Limpiado, Administrator
TIME COMPLETED:
02:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Gideon Limpiado was contacted by phone and arrived later to assist with the visit.
During the inspection, LPA and caregiving staff conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:
This is a one-story home with four bedrooms, three bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate supply of linen is present in the hallway closet. The bac yard has a shaded sitting area and both routes of egress are free of clutter and obstructions. LPA observed five residents. Bathrooms faucets and toilets were operational. Water temperature tested between 106 and 108 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers was observed to be fully charged with up-to-date maintenance. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed locked in a cabinet in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed five resident client files and five staff files. LPA interviewed staff and residents present.
Based on the observations made during today’s inspection, six deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and one Technical Violation Advisory Note is issued. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
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
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Document Has Been Signed on
02/13/2024 03:17 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 COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
CARE JORDAN 2
FACILITY NUMBER:
306005777
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation made during a tour of the physical plant, the licensee did not comply with the section cited above as supplements and potentially toxic substances were observed in the room of one of the residents, despite an assessment indicating resident cannot handle their own medication. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/14/2024
Plan of Correction
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2
3
4
Licensee removed and secured the dangerous items during the visit. Citation cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
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- 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 COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
CARE JORDAN 2
FACILITY NUMBER:
306005777
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on staff records reviewed during the visit, the licensee did not comply with the section cited above for two out of four current staff members, for which no annual training was provided in 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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4
Licensee will ensure all staff members receive adequate annual training and provide LPA with documentation of completion before the plan of corrections due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on a review of the facility's Medication Administration Records, the licensee did not comply with the section cited as the dispensed notes are observed to be documented only partially and not at the time of dispensation, thus rendering accurate accountability difficult. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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4
Licensee to schedule adequate medication administration training and ensure the correct documentation of administered doses. Proof of both will be submitted to LPA before the plan of corrections 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:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
3
of
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Document Has Been Signed on
02/13/2024 03:17 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 COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
CARE JORDAN 2
FACILITY NUMBER:
306005777
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based onrecords reviewed, the licensee did not comply with the section cited above. There have been no quarterly fire drills conducted at the facility since July 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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Licensee will resume conducting quarterly fire safethy drills and provide documentation to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on resident records reviewed, the licensee did not comply with the section cited above as four out of four residents with confirmed dementia diagnoses had not been reassessed in over a year, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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Physician reports will be updated and provided to LPA before the plan of corrections 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:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
02/13/2024 03:17 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 COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
CARE JORDAN 2
FACILITY NUMBER:
306005777
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(7)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews conducted,the licensee did not comply with the section cited above as there are no specific activities designed specifically for residents with dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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3
4
Licensee will resume conducting activities adapted to all residents in care, including these with dementia. Documentation of the activity program to be sent to LPA before the plan of corrections due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
5
of
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