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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005835
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:28:11 PM


Document Has Been Signed on 05/08/2024 12:28 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:KIRKWOOD ORANGEFACILITY NUMBER:
306005835
ADMINISTRATOR:ZEHRA SYEDFACILITY TYPE:
740
ADDRESS:1525 E TAFT AVENUETELEPHONE:
(714) 282-1409
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:66CENSUS: 44DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Executive Director- Megan BlacherTIME COMPLETED:
12:52 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit to the facility for an incident report received on April 24, 2024, that occurred on April 22, 2024. LPA De Perio explained the purpose of today's visit, was greeted by Executive Director (ED) Megan Blacher.

During this visit, LPA De Perio conducted interviews, and record review.

Per incident report, resident 1 (R1) had received a medication error, and that ED, Health and Wellness Director, R1's physician, and R1's responsible party were immediately notified. R1 was placed on a 48-hour observation and was assessed by the physician. An interview was conducted with R1 who expressed no health and safety concerns at the facility.

For this visit, citations were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with ED Blacher.

A copy of this report and Appeal Rights were provided and explained.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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 05/08/2024 12:28 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: KIRKWOOD ORANGE
FACILITY NUMBER: 306005835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing...
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidence by:
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As a plan of correction (POC), facility will provide proof of understanding of the regulation cited to the assigned LPA on or by 5/17/2024.
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Based on LPA's interviews, review of documents obtained and observations, resident 1 (R1) had a medication error due to being given double the dose of the prescribed medication. This poses a potential health and safety risk to residents in care.
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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) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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