306005835-8-21-2024-22-AS-KSGH-D8CVS9-20240821164111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005835
Report Date: 08/21/2024
Date Signed: 08/21/2024 04:43:24 PM

Document Has Been Signed on 08/21/2024 04:43 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 ORANGE		FACILITY NUMBER:	306005835
ADMINISTRATOR:	ZEHRA SYED		FACILITY TYPE:	740
ADDRESS:	1525 E TAFT AVENUE		TELEPHONE:	(714) 282-1409
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	66	CENSUS: 45	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Megan Blacher, Executive Director		TIME COMPLETED:	04:50 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 Analysts (LPAs) Kevin Saborit-Guasch and William Vanegas made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPAs were greeted and granted entry by facility front desk staff after introducing themselves and stating the reason of the visit. Executive Director Megan Blacher was present and assisted during the visit. During the inspection, LPAs and facility staff conducted a tour of the physical plant and observed the following: The facility is a two story residential building with a basement. There are assisted living and memory care units on each of the levels. There are currently a total of sixteen (16) residents in assisted living and twenty-nine (29) residents. There are six residents currently receiving hospice care. Assisted living units are either studios or one-bedroom apartments while memory care units are a combination of shared and individual studio units. All units are equipped with an en-suite bathroom equipped with anti-slip flooring and grab bars. All currently occupied resident bedrooms have the required furnishings. Vacant units are in the process of being renovated with new paint and new flooring. LPAs observed all beds have linens and blankets. Water temperature was verified to be within acceptable range in unit bathrooms located on both the ground level and second floor. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire and emergency drills have been conducted regularly as confirmed by a review of the facility's training records. LPAs accompanied by Executive Director additionally toured the basement level of the facility which includes storage observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are observed to be fully charged throughout the premises. Smoke detectors with sprinkler systems are centrally wired throughout the facility and have been checked by the fire department. A follow-up inspection is documented to be scheduled on August 28, 2024. 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: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005835
	VISIT DATE: 08/21/2024

NARRATIVE

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CONTINUED FROM FORM LIC809
There are two patios in the facility's courtyard, including a secure one adjoined to the facility's memory care unit. Both patios have shaded areas and outdoor furniture. The routes of egress are free of obstructions and accessed through delayed egress gates. Entry and exit into the memory care and outside the assisted living courtyard are also delayed egress devices.

There is one locked medication room on the second floor for residents under medication management. There were several locked janitorial closets for storage of toxins and cleaning equipment. An emergency call system is in place in each apartment and residents can be provided with a pendant and/or WanderGuard device depending on their needs and wishes. An activity room, outdoor patios, library and beauty salon were available for resident use. Activities are observed to be conducted through the duration of the visit.

Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure in three medication carts equipped with locks and stationed in the medication room. The facility uses electronic Medication Administration Records which was demonstrated by Med Tech staff during the visit. LPAs reviewed six resident files and eight staff files. Resident records include all necessary components, however two out of six physician reports were found to have been established over a year ago for two residents with an indication of dementia. Two staff members were observed to have been separated by mistake and were associated again during the visit.

Based on the observations made during today’s inspection, one type B deficiency is being issued per Title 22 Division 6 of the California Code of Regulations. Two Technical Assistance advisory note are issued regarding staff association and the operation of hand-washing facilities. 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: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/21/2024 04:43 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: 08/21/2024

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, two out of six resident files reviewed included an outdated medical assessment for residents with an indication of dementia. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2024
	Plan of Correction
1 2 3 4	Licensee will update the physician report for the two residents in question and provide the updated documentation to the Department before the plan of corrections 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: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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