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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005838
Report Date: 09/06/2024
Date Signed: 09/06/2024 01:30:11 PM


Document Has Been Signed on 09/06/2024 01:30 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:GENTLE CARING HOMEFACILITY NUMBER:
306005838
ADMINISTRATOR:LOURDES LAT, MARIAFACILITY TYPE:
740
ADDRESS:26762 CARLOTA DR.TELEPHONE:
(949) 874-4426
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Lat, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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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 facility administrator Maria Lat after introducing himself and stating the reason of the visit.

During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with four private bedrooms, two of which have en-suite bathrooms and the other two sharing a Jack-and-Jill bathroom, in addition to the facility's common living areas. Bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets.

There are currently four residents admitted to the facility, none of which are currently 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 and posted. Fire and emergency drills have been conducted quarterly as confirmed by staff interview but not formally documented. LPs provided consultation on the information needed to be maintained on file.
LPA 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.

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the house and routes of egress are free of obstructions.

Medication and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure. A bleach bottle and health supplements are however observed to be present and not secure during the walk-through.
CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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: GENTLE CARING HOME
FACILITY NUMBER: 306005838
VISIT DATE: 09/06/2024
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CONTINUED FROM FORM LIC809
LPA reviewed four resident files and three staff files. Resident records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location. Per observation, interview and records reviewed, one resident was confirmed to have been assessed as bedridden and requiring a Hoyer lift to be transferred out of the bed. The current fire clearance for the facility does not include any provision for a bedridden resident.

Based on the observations made during today’s inspection, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Three Technical Assistance advisory notes are provided as well with a consultation on the emergency and fire drills documentation, sufficient staffing requirements as well as the required Infection Control Plan. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 09/06/2024 01:30 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: GENTLE CARING HOME
FACILITY NUMBER: 306005838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as one bottle of bleach was found in the sink of one resident bathroom and health supplements were observed in the unlocked staff bedroon. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee placed the potentially dangerous items out of reach of residents during the visit. Deficiency cleared.
Type B
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as one resident was confirmed to have been assessed as currently bedridden in spite of the fire clearance not including that level of care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2024
Plan of Correction
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Licensee has verbally informed the resident and their reporting party that the facility was no longer an appropriate placement due to the resident's required level of care. Licensee intends to formally notify both the resident and their responsible party so an appropriate relocation can be conducted.
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: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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