306005806-9-19-2024-22-AS-KSGH-D99VTY-20240919164354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005806
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:44:40 PM

Document Has Been Signed on 09/19/2024 04:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	WE CARE SENIOR LIVING		FACILITY NUMBER:	306005806
ADMINISTRATOR:	SANSANO, CHERRYL		FACILITY TYPE:	740
ADDRESS:	24322 BARK ST.		TELEPHONE:	(949) 446-9841
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Cherryl Sansano, Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and William Vanegas made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Individual Benidict Estrella. LPA met with Administrator (AD) Cherryl Sansano and explained the purpose of the inspection. LPA reviewed list of Guardian roster for facility and all staff members present were listed and background cleared. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: This is a two-story home with the upstairs area only used by live in staff and is inaccessible to residents. The home has four resident bedrooms, two shared and two private with two staff bedrooms located on the second level. The home has two bathrooms, one shared and one within a shared room. The home has an attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 115.0 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Gas stove, microwave, washer, and dryer appear to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents in the bathroom and laundry room. Medication cabinet was observed to be locked; however, medication is being pre-poured into a plastic weekly medication organizer and in cups for each resident; a Deficiency was cited on this date on the attached form LIC809-D CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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 09/19/2024 04:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WE CARE SENIOR LIVING	FACILITY NUMBER: 306005806
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and staff interview, the licensee did not comply with the section cited above as the proof of current administrator certification is not available for display as it has not been received. This which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2024
	Plan of Correction
1 2 3 4	Licensee will contact the Administrator Certification Branch to follow up on the status of the renewal application. A status update will be provided to LPA before the plan of corrections due date.

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview, the licensee did not comply with the section cited above as medication appears to be prepared over 24 hours ahead of the time of administration. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2024
	Plan of Correction
1 2 3 4	Licensee will conduct an in-service training to ensure the scheduling of medication preparation is made less than 24 hours before the dispensation is conducted.

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 8

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: WE CARE SENIOR LIVING	FACILITY NUMBER: 306005806
	VISIT DATE: 09/19/2024

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CONTINUED FROM FORM LIC809
LPAs reviewed five resident files and three staff files. One out of the three staff files was observed not consisting of required staff documents such as TB test, Personnel record, CPR training, and 20 hours of required training. LPAs provided a Technical Advisory Note for the staff record not being present in the facility at the time of the visit. AD advised that she has the staff members files, but at another facility. Three of three resident files were complete and consisted of all required documentation for residents residing in the facility. LPAs interviewed one resident and one staff member.

Based on the observations made during today’s inspection, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations as well as two Technical Violation and three Technical Advisory Notes. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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