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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005780
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:58:01 PM


Document Has Been Signed on 07/29/2024 04:58 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: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:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shellad Yturralde, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 1:00 PM. During today’s visit, LPA met with Shellad Yturralde, Administrator Designee and Uldarico Almiranez (AD) via telephone.

The facility is a single story building with an approved fire clearance of six non-ambulatory residents of which six may be on hospice. The facility currently has a census of three residents in care.

At 1:05 PM LPA toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in two of two resident bathrooms. The hot water temperature measured between 112.6 and 113.1 degrees Fahrenheit. At 1:11 PM LPA observed when necessary, PRN, medications in non-ambulatory bathroom #2 in which a deficiency is cited, Staff immediately placed meds in locked centrally stored medication cabinet.

At 3:30 PM testing of smoke detectors, carbon monoxide and auditory devices on all exits were operational. The fire extinguisher is charged and was serviced on March 19, 2024. The facility’s last fire drill was conducted in 2023 and a Technical Violation will be given. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

LPA reviewed three of three staff training and fingerprint records and reviewed three of three resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on April 10, 2026.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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 07/29/2024 04:58 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: CANDLEBERRY CARE
FACILITY NUMBER: 306005780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview the licensee did not comply with the section cited above in two of three residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Shellad Yturralde, with AD Almiranez, will update the Medication Administration Record (MAR) to include PRN medications for two residents. PRN meds were immediately taken from restroom and locked with centrally stored medications.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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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: CANDLEBERRY CARE
FACILITY NUMBER: 306005780
VISIT DATE: 07/29/2024
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The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Shellad Yturralde, AD Designee, and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC 9102-TV and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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