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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005898
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:38:53 PM

Document Has Been Signed on 09/26/2023 03:38 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:ELEONOR'S PLACE 3FACILITY NUMBER:
306005898
ADMINISTRATOR:AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:26711 VALPARISO DRIVETELEPHONE:
(949) 547-5377
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
09/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Filomena Barela, Mark CruzTIME COMPLETED:
03:53 PM
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following on a self-reported incident report received in the Orange County Regional Office (OCRO) on 09/12/23 regarding a medication error involving Resident #1 (R1) that took place on 09/07/23. LPA met with Staff #1 (S1) Filomena Barela and discussed the purpose of the inspection. Administrator (AD) Mark Cruz arrived during the inspection.

The incident report states the following: On 09/07/23, R1 was given the wrong medication, had an adverse reaction which subsided, was seen by a doctor via telehealth, and did not need additional medical treatment.
During today’s inspection, LPA conducted health and safety checks on R1 and the other residents and observed no health and safety issues. LPA interviewed AD, R1, and requested and reviewed copies of the resident roster, staff roster, and Medication Administration Records.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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 09/26/2023 03:38 PM - It Cannot Be Edited


Created By: Sean Haddad On 09/26/2023 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELEONOR'S PLACE 3
FACILITY NUMBER: 306005898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2023
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee stated they will provide medication training from a pharmacy for all care staff and will submit proof to LPA by POC due date.
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Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications due to a medication error which resulted in an adverse reaction, which posed an immediate health risk to persons 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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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