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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005780
Report Date: 03/01/2023
Date Signed: 03/01/2023 02:02:00 PM


Document Has Been Signed on 03/01/2023 02:02 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: 5DATE:
03/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Shellad Yturralde, Caregiver, Socrates Yturralde, Caregiver and Uldarico"Rico" Almiranez (Via Telephone)TIME COMPLETED:
02:05 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted a Case Management- Deficiencies visit in conjunction to Complaint Control #22-AS-20230224131142 ten day inspection visit. LPA Quiroz identified herself and discussed purpose of today's visit to Licensee/Administrator (L/AD) Uldarico Almiranez via telephone who indicated not being able to be present during today's visit and that caregivers present at the facility would be able to assist LPA Quiroz during today's visit.
While investigating complaint control #22-AS-20230224131142, LPA Quiroz reviewed documents for Resident 1 (R1). Based on record review, the licensee did not comply with California Code of Regulations (CCR) 87202(a)(2).
During record review, LPA Quiroz observed (R1) has bedridden status per physician report dated 05/24/2020. (R1) was admitted into the facility on 5/15/2021. Facility does not have bedridden fire clearance, this was verified with (L/AD) Uldarico Almiranez via telephone. This poses an immediate health and safety risk to persons in care. CIVIL PENALTY ASSESSED.

Facility is being cited under CCR 87202(a)(2)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. (2)Bedridden persons.

An exit interview was conducted with (L/AD) Almiranez via telephone and Caregiver Socrates Yturralde and a copy of today's report, LIC 811- Confidential names, LIC 809-D, Appeal Rights and LIC 421IM Civil Penalty Assessment were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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 03/01/2023 02:02 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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/01/2023
Section Cited

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87202(a)(2):Fire Clearance
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notifythe licensing agency and obtain an appropriate fire clearance approved CONT...
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Licensee to submit for a bedridden fire clearance and forward proof to LPA by POC due date of 3/2/2023.
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CONT...by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.(2)Bedridden persons. This requirement was not met based on record review for Resident 1(R1). (R1) was admitted into the facility on 5/15/2021 CONTINUED...
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Based on record review, the licensee did not comply with the section cited above. LPA observed (R1) has bedridden status per physician report dated 05/24/2020. Facility does not have bedridden fire clearance. This poses an immediate health and safety risk to persons in care.CIVIL PENALTY ASSESSED.

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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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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