306005916-6-17-2024-22-AS-EKIM-D6C2B3-20240617171428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005916
Report Date: 06/17/2024
Date Signed: 06/17/2024 05:15:09 PM

Document Has Been Signed on 06/17/2024 05:15 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:	VICTORIA CARING HOME		FACILITY NUMBER:	306005916
ADMINISTRATOR:	MIRABUENO, MARIA PRICILLA		FACILITY TYPE:	740
ADDRESS:	6462 FERNE AVE		TELEPHONE:	(714) 952-9242
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	6	CENSUS: 6	DATE:	06/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Maria Pricilla Mirabueno		TIME COMPLETED:	05:20 PM

NARRATIVE

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On June 17, 2024 at 10:30am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator Maria Mirabueno and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory and have a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, attached 2-car garage, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant. There are no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 111.2 degrees F and 111.5 degrees F. A comfortable temperature of degrees 77 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, and supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and was serviced on September 1, 2023, and smoke detectors/carbon monoxide detectors were operable. The facility conducted Fire/Safety Drill on June 4, 2024 and does it quarterly. A working telephone (714-952-9242) remains available. First Aid Kit contained all the necessary elements.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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: VICTORIA CARING HOME	FACILITY NUMBER: 306005916
	VISIT DATE: 06/17/2024

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During the visit, LPs\A Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA conducted an audit of resident files (R1-R6), staff files (S1-S4), and medication and medication administration review. LPA Kim conducted resident interviews and staff interviews.

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of this report was provided to Administrator Maria Mirabueno.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/17/2024 05:15 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: VICTORIA CARING HOME	FACILITY NUMBER: 306005916
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355 (e ) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. LPA observed in record review of S3 and S4 were not associated to the facility. This poses an immediate health, safety, and personal rights risk to persons in care.
	POC Due Date: 06/18/2024
	Plan of Correction
1 2 3 4	Licensee states they will associate S3 and S4 and provide proof to CCLD via email to Edward.kim@dss.ca.gov by June 18, 2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

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