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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005927
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:34:27 PM


Document Has Been Signed on 03/18/2024 03:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ELEONOR'S PLACE 4FACILITY NUMBER:
306005927
ADMINISTRATOR:AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:24431 ZANDRA DRIVETELEPHONE:
(949) 547-5377
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mark Cruz, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Mark Cruz was contacted by phone and arrived later to assist with the visit.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with five resident bedrooms, one staff room and two bathrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded sitting area and the route of egress is free of clutter and obstructions. There are currently six residents in care at the facility, four of which are receiving hospice care. Bathrooms faucets and toilets were operational. Water temperature tested close to 120F which prompted LPA to provide a consultation on water temperatures. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Sharps were observed locked in a drawer in the kitchen. LPA observed cleaning supplies to be stored in a locked cabinet under the kitchen sink and in the laundry area, however laundry detergent was observed to be accessible. A lock was installed on the laundry room's door during the visit. The medication central storage was also observed to be secure. LPA reviewed six resident files and four staff files and interviewed one staff present.

Based on the observations made during today’s inspection, four type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. One Technical Advisory and one Technical Violation advisory notes are also being issued to the licensee. 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: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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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Document Has Been Signed on 03/18/2024 03:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ELEONOR'S PLACE 4
FACILITY NUMBER: 306005927

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Per CCR 87608(a)(5)(B): "(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 resident is observed to have been discharged from hospice on March 17, 2024 but their full rails were still in place during the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Licensee instructed staff present to remove the full bed rails as the resident discharged from hospice was no longer allowed to be provided the specific postural support. Deficiency cleared during the visit.
Type B
Section Cited
HSC
1569.695(c)
Per Health and Safety Code Section1569.695(c): "A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above as there have been not scheduled drills. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Licensee is meeting with a third-party provided for emergency and disaster training on March 21, 2024 and will elaborate a drill plan and schedule which will be provided to LPA before the Plan of Corrections due date.
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: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 03/18/2024 03:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ELEONOR'S PLACE 4
FACILITY NUMBER: 306005927

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(2)
Per CCR 87633(a)(2): "The licensee remains in substantial compliance with the requirements of this section, (...) and with all terms and conditions of the waiver."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above as there were a total of 5 resident receiving hospice care until one resident was discharged on March 17, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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At the time of the visit, the licensee is no longer receiving hospice care in excess of the allowed waiver which states a capacity of four hospice residents. Deficiency cleared during the visit. In the event licensee plans to admit more residents requiring hospice care, additional waiver capacity should be requested and granted ahead of time.
Type B
Section Cited
CCR
87705(f)(2)
Per the California Code of Regulations Section 87705(f)(2): "f) The following shall be stored inaccessible to residents with dementia: cleaning supplies and disinfectants.:

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 laundry detergent was observed to be stored unsecured on top of the washing machine in an unlocked laundry room. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Facility staff placed the detergent in a locked cabinet during the visit and a lock was observed to be installed on the laundry room door. The deficiency was cleared during the visit.
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: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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