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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005780
Report Date: 10/24/2022
Date Signed: 10/24/2022 02:44:01 PM


Document Has Been Signed on 10/24/2022 02:44 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CANDLEBERRY CAREFACILITY NUMBER:
306005780
ADMINISTRATOR:ROSARIO, ROBERTO DELFACILITY TYPE:
740
ADDRESS:4216 CANDLEBERRY AVE.TELEPHONE:
(949) 290-6006
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY:6CENSUS: 3DATE:
10/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Udarico "Rico" AlmiranezTIME COMPLETED:
01:26 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to Candleberry Care. LPA Rosie Quiroz was COVID-19 screened and allowed entry into the facility by caregiver 1.

Licensee/ Administrator (L/AD) Udarico Almiranez arrived to facility shortly after. The purpose of today's Case Management-Incident visit was to follow-up on an incident report dated 10/20/2022 received at Community Care Licensing Orange County Regional Office on 10/21/2022 regarding Resident 1 (R1).

On today's visit LPA Quiroz conducted interviews with interviewees and conducted tour of interior and exterior of facility premises. On today's date, LPA Quiroz reviewed the following documentation for (R1): Needs and Services plan dated 5/25/2022 and physician report dated 1/5/2022.

Based on today's interviews and documentation reviewed, facility is being cited. An exit interview was conducted with L/AD Udarico Almiranez and a copy of this report along with the LIC 811- Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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 10/24/2022 02:44 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CANDLEBERRY CARE
FACILITY NUMBER: 306005780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited

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87224(a) Eviction Procedures: (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by:
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Based on interviews conducted during today's visit. L/AD Almiranez evicted Resident 1 on 10/17/2022 verbally and did not provide a 30 day notice. This was verified with L/AD Amiranez. This poses an immediate 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: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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