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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005845
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:34:43 PM


Document Has Been Signed on 02/09/2024 04:34 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:SANTA MARIANA CAREFACILITY NUMBER:
306005845
ADMINISTRATOR:LIMPIADO, GIDEONFACILITY TYPE:
740
ADDRESS:18676 SANTA MARIANATELEPHONE:
(949) 349-8708
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Dory Cabrera, Caregiver and Roel Atanacio, House ManagerTIME COMPLETED:
04:35 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called Administrator (AD) Karmian Calangi and explained the nature of the visit. House Manager (HM) Roel Atanacio arrived during today's visit.

This facility is licensed to provide services to age range 60 and over, approved for six (6) Non-Ambulatory Residents of which 1 (one) may be bedridden and has a hospice waiver for four (4) residents. There are (2) two residents receiving hospice services.(AD) Calangi has an Administrator Certificate with expiration date of 6/20/2025.

LPA Rosie Quiroz along with (CG1) toured the interior and exterior of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility at this time. During today's inspection tour, LPA Quiroz observed five of six residents in their bedroom resting and of one of six residents in the living room area watching television with staff supervision. LPA Quiroz interacted and interviewed with staff and residents during today's visit. Between 12:52pm-1:20pm while conducting inspection tour of kitchen, LPA Quiroz observed expired condiments and other food items, with expiration dates varying from 7/12/2023- 2/6/2024. This was verified with (CG1) (CG2) and (HM) Roel Atanacio. (See LIC 809-D)

Between 1:30pm-1:40pm, while LPA Quiroz inspected resident's bedrooms and bathrooms. Water temperatures were recorded to be between 110.5-112.4 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. While inspecting Resident 6(R6s) bedroom area, LPA Quiroz observed medication in (R6s) bedroom area but not limited to Peptobismol, Zyrtec, Antacid tables, NyQuil and fluticasone nasal spray. This was verified with (CG1), (CG2) and (HM) Atanacio. (See LIC 809-D)

Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits.CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 02/09/2024 04:34 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: SANTA MARIANA CARE
FACILITY NUMBER: 306005845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
875559(b)(8)
GENERAL FOOD SERVICE REQUIREMENTS(b)(8): All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during facility inspection of kitchen area and interviews conducted with (CG1), (CG2) and (HM), the licensee did not comply with the section cited above. While inspecting kitchen area, LPA observed expired food items which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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During today's visit, (CG2) discarded expired food items. (AD) will provide inservice training on CCR 87555 to staff identified on LIC 500 by POC due date of 2/12/2024.
Type B
Section Cited
CCR
87705(f)(2)
CARE OF PERSONS WITH DEMENTIA 87705(f)(2): The following shall be stored inaccessible to residents with dementia(2)over the counter medication, nutritional supplements or vitamins...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and tecord review of Resident 6's bedroom area, the licensee did not comply with the section cited above. LPA Quiroz observed medication but not limited to peptobismol, antiacid tablets, Nyquil and fluticasone prescribed spray, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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(AD) Will provide inservice training to facility staff identified on LIC 500 and submit proof to CCL by 2/12/2024.
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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: SANTA MARIANA CARE
FACILITY NUMBER: 306005845
VISIT DATE: 02/09/2024
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CONTINUED...LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and facility entrance readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area backyard for residents and visitor's enjoyment in backyard area.

During today's visit, while LPA Quiroz provided Consultation on Title 22 and Infection control. Citation were issued during today’s visit.

An exit interview was conducted with (HM) Roel Atanacio via telephone and with (CG1) at the facility. A copy of this report, LIC 811-Confidential names, LIC 809-D and Appeal Rights were provided to facility staff at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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