306005832-9-17-2024-22-AS-KSGH-D97RME-20240917130839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005832
Report Date: 09/17/2024
Date Signed: 09/17/2024 01:09:40 PM

Document Has Been Signed on 09/17/2024 01:09 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:	SUMNER BOARD AND CARE		FACILITY NUMBER:	306005832
ADMINISTRATOR:	BUMANGLAG, ARVIN		FACILITY TYPE:	740
ADDRESS:	8652 SUMNER PL		TELEPHONE:	(714) 350-1052
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	6	CENSUS: 5	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Arvin Bumanglag, Administrator		TIME COMPLETED:	01:15 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by the facility's caregiving staff after introducing himself and stating the reason of the visit. Administrator Arvin Bumanglag was notified via telephone and arrived later to assist with the visit. During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with six private bedrooms in addition to the facility's common living areas and two attached garages. There is an additional room for use by live-in staff. There are five bathrooms including four en-suite bathrooms. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. Four beds are observed to be equipped with full rails and another one with half rails for postural support. Physician orders and hospice plan of care and admission reviewed for all residents on hospice. Hospice waiver capacity is six. There are currently five residents admitted to the facility, four of which are receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed. Drills are conducted quarterly and documented. The copy of the Emergency and Disaster Plan provided did not include the required temporary shelter locations. A Technical Assistance Advisory Note and consultation was provided during the visit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been replaced in August 2024. There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the property. The route of egress is free of obstructions. There are no bodies of water on the premises. 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: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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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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: SUMNER BOARD AND CARE	FACILITY NUMBER: 306005832
	VISIT DATE: 09/17/2024

NARRATIVE

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CONTINUED FROM FORM LIC809
Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed five resident files and six staff files. Resident records include all necessary components, however physician reports for three residents with dementia diagnoses are outdated and do not reflect the necessary annual reassessment. A type B deficiency is cited on an attached form LIC809-D. All staff members are confirmed to be cleared and associated with this particular licensed location. Training records and CPR training on file and up-to-date.

Based on the observations made during today’s inspection, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report along with 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: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/17/2024 01:09 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: SUMNER BOARD AND CARE	FACILITY NUMBER: 306005832
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as three out of five physician reports did not reflect an annual reassessment for residents diagnosed with dementia. 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 obtain updated medical assessment forms from the residents' current primary care providers and provide copies to LPA before the plan of correction's due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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