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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005785
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:07:10 PM


Document Has Been Signed on 07/26/2022 02:07 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:B & C ELDERLY CAREFACILITY NUMBER:
306005785
ADMINISTRATOR:ESTORBA, BRIAN A.FACILITY TYPE:
740
ADDRESS:9342 LIME CIRCLETELEPHONE:
(714) 488-8413
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 6DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Brian EstorbaTIME COMPLETED:
02:20 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Brian Estorba and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen and observed the following:

LPA and AD observed there were 2 staff present, wearing PPE. LPA observed 6 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.
During the inspection, LPA and AD observed the following: unsecured medications in a cabinet with a broken lock in the kitchen; unsecured sharps and knives in a non-lockable drawer in the kitchen. During the inspection, AD began the process of correcting these deficiencies and will submit proof of correction by POC due date.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA requested and reviewed resident roster, staff roster, resident files, emergency plan, and COVID-19 mitigation plan. LPA provided technical assistance regarding the Infection Control Plan, N95 Fit Testing, and PPE. LPA advised AD to review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan immediately.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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 5


Document Has Been Signed on 07/26/2022 02:07 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: B & C ELDERLY CARE
FACILITY NUMBER: 306005785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


87465 Incidental Medical and Dental Care (h) … (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure medications were inaccessible to residents in the kitchen, which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee stated they will secure the medications by fixing the lock on the medication cabinet in the kitchen and submit proof to LPA by POC due date.
Type A
Section Cited
CCR
87309(a)


87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure sharps and knives were inaccessible to residents in the kitchen, which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee stated they will secure the sharps and knives by adding a lock to the knife storage drawer and will submit proof to LPA by POC due date.

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 LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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