306005838-8-23-2022-22-AS-KSGH-CHL27F-20220823170839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005838
Report Date: 08/23/2022
Date Signed: 08/23/2022 05:08:51 PM

Document Has Been Signed on 08/23/2022 05:08 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:	GENTLE CARING HOME		FACILITY NUMBER:	306005838
ADMINISTRATOR:	LOURDES LAT, MARIA		FACILITY TYPE:	740
ADDRESS:	26762 CARLOTA DR.		TELEPHONE:	(949) 874-4426
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS:	DATE:	08/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Priscilla Sanchez, Administrator Maria Lat, License Guillermina Lara-Estrada, caregiver Imelda Sanchez Gonzales, caregiver		TIME COMPLETED:	05:20 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 08/23/2022 at 3:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing mostly on Infection Control procedures. LPA was greeted and granted entry by caregivers. Licensee Maria Lat was notified by telephone and arrived shortly afterwards to assist with the visit along with administrator Priscilla Sanchez. At approximately 4:00pm, LPA accompanied by livensee toured the physical plant of the facility. There are currently four (4) residents in care including one (1) resident receiving hospice care. The residents are observed relaxing in their respective bedrooms and appear clean and well taken care of. The five (5) bedrooms include all necessary components. An ample supply of linen is observed. The two (2) bathrooms are equipped with grab bars and slip mats along with hand washing signs. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are stored in a kitchen drawer secured by a key lock. The centrally stored medication and resident files are located in a secure cabinet with functional magnetic locks near the kitchen. Cleaning supplies are located in multiple locations (sink cabinets, kitchen cabinet, attached garage), all of which are secure. LPA observed a sufficient supply of food and water present along with emergency water clearly marked in the garage. LPA observed the facility has COVID-19 Precautions posters and all required department postings. The Administrator Certificate posted is however expired since 07/05/2021. Licensee was able to provide LPA with a current certificate during the visit. A Technical Advisory is issued regarding the requirement for an up-to-date certificate on the facility's premises. Staff present is adequately cleared in Guardian with the exception of caregiver S1 who is currently shadowing. A deficiency is being cited for lack of background clearance along with the assessment of an immediate civil penalty. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GENTLE CARING HOME	FACILITY NUMBER: 306005838
	VISIT DATE: 08/23/2022

NARRATIVE

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CONTINUED FROM FORM LIC809

LPA and licensee toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present for the enjoyment of residents and visitors. The perimeter gates are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises. A storage shed and a locked room dedicated to staff on their day off are also present in the backyard.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and a immediate civil penalty is assessed. One (1) Technical Advisory notice is issued regarding the requirement for an up-to-date administrator certificate. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2022 05:08 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: GENTLE CARING HOME	FACILITY NUMBER: 306005838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

The California Code of Regulations on Criminal Record Clearance Section 87355(e)(1) indicates that: "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: Obtain a California clearance or a criminal record exemption as required by the Department." This requirement is not met as evidenced by: During the visit, caregiver S1 was present shadowing caregiver S2. An inquiry in Guardian was not able to locate any background clearance obtained by caregiver.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review made during the visit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. An immediate civil penalty is being assessed.
	POC Due Date: 08/24/2022
	Plan of Correction
1 2 3 4	Licensee will ensure staff S1 has satisfied the requirement of CCR Section 87355(e)(1) before being added to the facility schedule and working at the facility.

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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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