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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005809
Report Date: 08/24/2022
Date Signed: 08/24/2022 06:18:14 PM


Document Has Been Signed on 08/24/2022 06:18 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:BRITTA CAREFACILITY NUMBER:
306005809
ADMINISTRATOR:MANGISI, FRANKFACILITY TYPE:
740
ADDRESS:106 S JEANINE WAYTELEPHONE:
(714) 630-4791
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Frank MangisiTIME COMPLETED:
06:40 PM
NARRATIVE
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On 08/24/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Britta Care. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 11:47am, LPA Cho was allowed entry into the facility and met with Caregiver Brenda Baladec after completing the Coronavirus 2019 (COVID-19) screening procedure. Facility utilized a digital thermometer in lieu of a contactless thermometer. Admin was advised to obtain a contactless thermometer which was purchased during the visit. Caregiver Saturnina Santander was also present at this time. LPA verified with Staff 1 (S1) and then the Administrator (Admin) Frank Mangisi who both acknowledged that Staff 2 (S2) was employed as a reliever effective 08/21/2022. At 12:10pm, Admin also confirmed and acknowledged that S2 was not associated to the facility on Guardian. LPA also verified the information via the Licensing Information System (LIS) Personnel Report Summary. Admin agreed to having S2 return to the facility once a transfer of records and association have been finalized. Admin arrived at the facility at 12:13pm. As of today, there are no active COVID-19 cases in the facility. Facility screens visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. LPA observed the Complaint Poster was not in the correct size, and LPA advised Admin to obtain one in the correct size of 20" by 26". The facility is licensed for two ambulatory and four non-ambulatory residents and has a hospice waiver for six. There are currently six residents living in the facility of which three are receiving hospice care.

At 12:15pm, LPA Cho conducted a tour of the physical plant along with Administrator Frank Mangisi. The single story home consists of six resident bedrooms with four resident bathrooms. There is one staff bedroom. The facility also has a living room, dining area, office area, kitchen, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly except in Bathroom #1. Bathroom #1 had a left faucet handle cover that was half-broken which exposed the inner metal bar.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 13


Document Has Been Signed on 08/24/2022 06:18 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: BRITTA CARE
FACILITY NUMBER: 306005809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews of Administrator and staff, the facility did not ensure one out of two staff was associated to the facility as required prior to employment which poses an immediate Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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2
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Licensee acknowledges and agrees to associate S2 and to forward proof of correction by POC due date.
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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2022 06:18 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: BRITTA CARE
FACILITY NUMBER: 306005809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did not ensure that six out of six resident pill box organizers, staff medications, and bug sprays were locked and inaccessible to the residents which poses an immediate Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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Licensee agrees to fully secure all medications and toxic solutions which was corrected during the visit. Facility to provide training to all staff handling medications and toxic substances. Proof of training shall be forwarded to LPA by POC due date.
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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
Page: 5 of 13


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: BRITTA CARE
FACILITY NUMBER: 306005809
VISIT DATE: 08/24/2022
NARRATIVE
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Grab bars were secure, showers was free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 114.4 degrees Fahrenheit in the Bathroom #1, 116.6 degrees Fahrenheit in Bathroom #2, 110.6 degrees Fahrenheit in Bathroom #3, and 117.8 degrees Fahrenheit in Bathroom #4.

LPA Cho inspected the kitchen along with Admin. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged but serviced on 03/04/2021. Admin scheduled an appointment during the visit and confirmed the appointment day to be on or before 08/26/2022. At 3:27pm, the smoke and carbon monoxide detectors were tested and operational. Sharps were locked and inaccessible, but resident medications, caregiver medications, and toxins were unlocked and accessible to the residents in care. At 12:23pm, LPA observed Robafen Congestion Formula, two spray cans of Raid, and thirteen unpackaged supplement pills as well as six residents' pill plastic organizers in the caregiver's room due to the caregiver's bedroom being unlocked. The locking mechanism was installed and completed during the visit at 3:07pm. Around 12:06pm, LPA observed five bottles of cleaning solutions in an unlocked cabinet underneath the sink. Caregiver Baladec locked the cabinet immediately during the visit. The auditory alarms throughout the facility were not in operating condition as the alarms in Bedrooms #2, #4, and #5 required a new battery. Both sliding door and the exit door located in the living room did not have an auditory alarm. LPA requested Admin to obtain and install an auditory alarm on each door. The auditory devices were installed and corrected during the visit.

LPA Cho toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gates were self-closing and self-latching. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Admin was advised to update the LIC610E form per Assembly Bill (AB) 3098 released on 12/13/2018 and as required per the Provider Information Notice (PIN 18-18-ASC). Facility has back-up emergency food and water supply. The First Aid Kit met all the required components except a first aid manual, and the facility had sufficient PPEs.


SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BRITTA CARE
FACILITY NUMBER: 306005809
VISIT DATE: 08/24/2022
NARRATIVE
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Resident files for (R1, R2, and R3) were reviewed. Staff files were not reviewed at the time of this visit. LPA reviewed the COVID-19 mitigation plan of the facility as well as Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility does have an existing internet service and provides the residents a smart phone upon request.

LPA provided the following guidance: to update the LIC610E using the current form, to obtain a first aid manual and the PUB475 in the correct size of 20"x26," to ensure all medications, toxins, and cleaning solutions are locked and inaccessible to the residents, to ensure the facility is in good repair at all times, to annually service the fire extinguisher, and to ensure S2 is associated prior to employment. In addition, LPA reminded Administrator Mangisi the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, deficiencies are cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Frank Mangisi, and a copy of this report (including LIC809, LIC809C, LIC809D, Civil Penalty Assessment LIC421, LIC9102s, and the appeal rights) were provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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