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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005937
Report Date: 06/14/2024
Date Signed: 06/14/2024 02:16:14 PM


Document Has Been Signed on 06/14/2024 02:16 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:DEL'S HAVEN IIIFACILITY NUMBER:
306005937
ADMINISTRATOR:MANALO, DIANNAFACILITY TYPE:
740
ADDRESS:29825 ANDREA WAYTELEPHONE:
(949) 481-2444
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Dianna ManaloTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Dianna Manalo and explained the reason for the visit. The Administrator's certificate expires November 15, 2025. The facility is a single story home that has 4 bedrooms and 2 bathrooms, living room, dining room, kitchen and an activity room and a 2 car garage. LPA and Administrator toured the facility. LPA observed the see something say something poster (PUB 475) posted in the entry way of the facility. LPA observed that the resident bedrooms are clean and organized. LPA observed all the resident bedrooms had the required furnishings. LPA observed that the living room is being used as a shared bedroom for two residents. The living room does have double doors leading outside to the front court yard. LPA observed both bathrooms are clean and operational. Hot water measured 110.0 degrees Fahrenheit. Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the kitchen is fully charged. LPA observed the kitchen is clean and organized. LPA observed a two day perishable and seven day non-perishable food supply on hand in the kitchen. LPA observed the knives and sharp objects are kept locked in a kitchen drawer and the cleaning supplies are kept locked under the kitchen sink. The activity room has 4 reclining chairs and a sofa. There is also a TV in the activity room. Medications are kept locked in the cabinet in the dining room. The garage is inaccessible to residents and kept locked. The garage is used for storage of supplies and furniture. LPA and the Administrator toured the backyard. Both exit gates are operational. LPA observed old furniture such as a bed, chair, table and wheelchairs and supplies stored in the backyard and the side of the house. No bodies of water observed. LPA reviewed 3 staff files. LPA observed that 1 out of 3 staff files (Staff 2) did not have a completed health screening. LPA observed that 2 out of 3 staff did not have 20 hours of the annual required training (Staff 2 and Staff 3). LPA reviewed 4 resident files, no discrepancies observed. LPA reviewed 4 resident medications, no discrepancies observed. LPA inspected the first aid kit. The first aid kit has all the required items. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted with the Administrator and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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 06/14/2024 02:16 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: DEL'S HAVEN III

FACILITY NUMBER: 306005937

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

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, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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LIcensee must relocate the residents and have the room return to use as a living room. Licensee can relocate residents to a shared or room or request a legal evication from the Agency. Licensee to provide a documented plan on how to relocate residents and begin the relocation process by the POC due date.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 out of 3 staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee agrees to get a current health screening for Staff 2. Licensee to submit proof to LPA by the POC 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: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/14/2024 02:16 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: DEL'S HAVEN III

FACILITY NUMBER: 306005937

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above for 2 out of 3 staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee agrees to have all staff trained in compliance with the regulation above. Licensee agrees to forward proof of training for Staff 2 and Staff 3 by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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