306005777-3-19-2024-22-AS-KSGH-D3J29N-20240319171214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005777
Report Date: 03/19/2024
Date Signed: 03/19/2024 05:12:42 PM

Document Has Been Signed on 03/19/2024 05:12 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: 6	DATE:	03/19/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	03:57 PM
MET WITH:	Gideon Limpiado, Administrator (via telephone)		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the plan of corrections for five (5) of the six (6) deficiencies cited during the required annual inspection that was conducted on February 13, 2024. LPA was greeted and granted entry by facility staff after explaining the reason of the visit. Administrator Gideon Limpiado was notified of the visit via telephone and could not assist in person. A type B citation for failure to meet the requirements of Health and Safety Code section 1569.695(c) was issued with a plan of corrections stating that: "Licensee will resume conducting quarterly fire safety drills and provide documentation to LPA before the plan of corrections due date." At the time of the present visit, per staff interview conducted there have been no additional documented drills nor any plan to conduct or schedule one. A type B citation for failure to meet the requirements of CCR 87705(c)(5) was issued. Plan of corrections stated "Physician reports will be updated and provided to LPA before the plan of corrections due date." At the time of the visit, one of the outdated physician reports was shown to have been updated for resident R1, however three others are still pending with no indication of when they will be provided. Per staff interview conducted, the activity program was updated and residents are offered activities outside of the facility such as bingo held at another of the licensee's licensed locations nearby. The deficiency is cleared. The Medication Administration Records were reviewed during the visit and observed to be up-to-date at this time. The corresponding deficiency is also cleared. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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 2

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
	VISIT DATE: 03/19/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

CONTINUED FROM FORM LIC809
A type B citation for failure to meet the requirements of the Health & Safety Code Section 1569.625(b)(2) was also issued. The plan of corrections (POC) stated that "Licensee will ensure all staff members receive adequate annual training and provide LPA with documentation of completion before the plan of corrections due date." No proof of annual training being conducted since February 13, 2024 could be provided at the type of the visit.

Three Civil Penalties assessed for failure to correct deficiencies by the POC due date of March 13, 2024 are being assessed at this time.

An exit interview was conducted and a copy of this report along with the assessed civil penalties on three separate forms LIC421FC as well as appeal rights were provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2