306005778-5-10-2024-22-AS-FLAA-D55RSE-20240510131638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005778
Report Date: 05/10/2024
Date Signed: 05/10/2024 01:17:24 PM

Document Has Been Signed on 05/10/2024 01:17 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:	ANNISSA GEM CARE		FACILITY NUMBER:	306005778
ADMINISTRATOR:	LIMPIADO, GIDEON		FACILITY TYPE:	740
ADDRESS:	825 LILAC DRIVE		TELEPHONE:	(714) 203-1702
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 6	DATE:	05/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Karmian Calangi- Administrator		TIME COMPLETED:	01:30 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	Licensing Program Analysts (LPAs) Faith La and Dwayne Mason Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit and were greeted and granted entry by the house manager Anthony Deguzman. The house manager Anthony Deguzman notified facility administrator (AD) Karmian Calangi about the visit, and AD Karmian Calangi came to facility shortly after. For today’s visit, LPAs observed a total of 6 residents in care and 3 staff members on duty. LPAs observed the Administrator's Certificate which expires on 06/20/2025. LPAs observed the PUB475 “See Something Say Something” poster was located and posted at entrance. LPAs toured the interior and exterior portions of the facility with house manager Anthony Deguzman. The facility is a one level structure and is licensed for 6 non-ambulatory residents, of which 4 may be on hospice and 1 may be bedridden. For this visit, there are a total of 6 residents in care. There are a total of 7 bedrooms, of which 4 are private resident rooms, 1 is a shared resident room and 2 are private rooms for staff. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which 1 is for staff and 2 are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in 2 restrooms were measured to be at 124.1 and 124 degrees Fahrenheit. A deficiency is being issued. Staff lowered the water heater and measured at 119.4 and 120 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies requirement. Sharp items and knives were located in cabinet in kitchen and were observed to be locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen, and the service date was March 05, 2020. A deficiency is being issued.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Faith La	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2024 01:17 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: ANNISSA GEM CARE	FACILITY NUMBER: 306005778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidence by based on observation it was observed the Adminitrator did not ensure the facility's Fir extingisher was serviced on March 05, 2020, which poses an immediate health and safety risk to the person in care.
	POC Due Date: 05/11/2024
	Plan of Correction
1 2 3 4	Administrator reach out to have the fire extinguisher serviced the same date of inspection, and willl submit proof of correction through email by the assigned POC due date of 05/11/2024.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidence by based on observation, two out of two resident's bathrooms had hot water measured over 120 degree Fahrenheit which poses an immediate health and safety risk to the person in care,
	POC Due Date: 05/11/2024
	Plan of Correction
1 2 3 4	During inspection, the house manager adjusted hot water. LPAs measured hot water to be between 105 and 120 degree Fahrenheit. POC was fulfilled during inspection.

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: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Faith La	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANNISSA GEM CARE	FACILITY NUMBER: 306005778
	VISIT DATE: 05/10/2024

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LPAs observed the emergency disaster and evacuation plan, which is posted in the entrance. Facility had back-up emergency food and water supply, located in the hallway. LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPAs observed patio furniture under shading, and the grounds were free of any hazards. There is 1 gate in the backyard, which was self-closing and self-latching. No bodies of water were observed.
For today's visit two deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with AD Karmian Calangi. A copy of this report was provided and explained.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Faith La	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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