306005801-12-30-2024-22-AS-EBEY-DCFVRU-20241230154032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005801
Report Date: 12/18/2024
Date Signed: 12/30/2024 03:40:47 PM

Document Has Been Signed on 12/30/2024 03:40 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:	CARINGBRIDGE INC.		FACILITY NUMBER:	306005801
ADMINISTRATOR/ DIRECTOR:	STAN, CRISTIANA		FACILITY TYPE:	740
ADDRESS:	2421 E POWHATAN AVE		TELEPHONE:	(714) 833-5589
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Rodica Cristea - Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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On December 18, 2024, at 8:30am, Licensing Program Analysts (LPAs) Eboni Bentley and Edward Kim accompanied by Licensing Program Manager (LPM) Lourdes Montoya, conducted an unannounced required 1-year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs Bentley and Kim were greeted and granted entry by Caregiver (CG) Rodica Cristea. Administrator (AD) Christina Stan arrived at the facility around 10:00am.

The facility is licensed to operate for six (6) residents which can be one (1) ambulatory, (5) non-ambulatory, one (1) bedridden and have a hospice waiver for two (2) residents. This is a two-story structure located in a residential neighborhood and consists of the following: five (5) resident bedrooms, four (4) bathrooms, (1) staff bedroom, living room, dining area, kitchen, an outdoor area with covered seating, and an attached two car garage.

LPAs Bentley and Kim toured inside and outside of the physical plant with AD Stan. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be clean and operational. The water temperature was measured at 112.8 degrees F to 117.3 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills was last conducted on September 30, 2024 and conducted quarterly. First aid kit is maintained and contains all the necessary elements.

Lourdes Montoya	TELEPHONE: (714) -705-6014
Eboni Bentley	TELEPHONE: 714-552-7883
	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

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 12/30/2024 03:40 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: CARINGBRIDGE INC.	FACILITY NUMBER: 306005801
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personal Accommodations and Services

(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. The facility fireplace in the living room did not have a screeen covering which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to provide a screen covering for the fireplace by the due date. POC shall be submitted to CCLD via email to eboni.bentley@dss.ca.gov.

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. The administaror, one staff, and one volunteer did not have personnel files, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to complete all three personnel records by the due date. POC shall be submitted to CCLD via email to eboni.bentley@dss.ca.gov.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (714) -705-6014
Eboni Bentley	TELEPHONE: 714-552-7883
	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2024 03:40 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: CARINGBRIDGE INC.	FACILITY NUMBER: 306005801
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. Three out of five residents did not have current annual medical assessments and appraisals, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to complete all three residents' medical assessments and appraisals by the due date. POC shall be submitted to CCLD via email to eboni.bentley@dss.ca.gov.

Section Cited

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. Two residents with Dementia did not have current annual medical assessment and appraisal, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to complete all two residents' medical assessments and appraisals for residents with Dementia by the due date. POC shall be submitted to CCLD via email to eboni.bentley@dss.ca.gov.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (714) -705-6014
Eboni Bentley	TELEPHONE: 714-552-7883
	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

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: CARINGBRIDGE INC.	FACILITY NUMBER: 306005801
	VISIT DATE: 12/18/2024

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During the visit, LPA Bentley observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-833-5589) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has one (1) fire extinguisher that was charged, mounted in the kitchen, and serviced on June 25, 2024. Liability Insurance is effective 3/4/2024 through 3/4/2025.

LPA Bentley conducted an audit of five (5) resident files (R1-R5), three (3) staff files (S1-S3), and medication administration record review. LPA Kim conducted three (3) staff interview and three (3) resident interviews.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Christina Stan.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -705-6014
LICENSING EVALUATOR NAME: Eboni Bentley	TELEPHONE: 714-552-7883
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC809 (FAS) - (06/04)

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