306005939-9-20-2022-22-AS-JCHO-CJFVHQ-20220920162730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005939
Report Date: 09/20/2022
Date Signed: 09/20/2022 04:29:18 PM

Document Has Been Signed on 09/20/2022 04:29 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:	ADULT CARE OC I		FACILITY NUMBER:	306005939
ADMINISTRATOR:	SCHOTT, BRIAN		FACILITY TYPE:	740
ADDRESS:	25032 WOOLWICH ST		TELEPHONE:	(626) 864-9955
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 4	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:07 PM
MET WITH:	Brian Schott		TIME COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/20/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Adult Care OC I. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 2:14pm, LPA Cho was greeted and allowed entry by Care Staff Demetrey Dicen and completed the Coronavirus 2019 (COVID-19) screening procedure. Care Staff Erwin Calibara was also present today. Licensee/Administrator (Admin) Brian Schott greeted LPA around 2:20pm. Administrator (Admin) Fe Szalonek joined shortly after around 2:28pm. As of today, there are no active COVID-19 cases. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs throughout the facility. The Complaint Poster (PUB475) met the size requirement. The facility is licensed for one ambulatory, five non-ambulatory residents, and has a hospice waiver for six. There are currently five residents living in the facility of which three are receiving hospice care. At 2:30pm, LPA Cho conducted a tour of the physical plant with Licensee Schott and Admin Szalonek. The two-story home consists of five resident bedrooms and four resident bathrooms. There is one staff bedroom and bathroom. On the first floor, the facility also has a living room, dining room, staff break room (with a bed), kitchen, and an attached two car garage with a laundry area. The second floor is the living area for the Licensee/Admin Schott. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA observed a mounted camera above the doorframe in the bedroom of Resident 1 (R1). Per Licensee Schott, the family of R1 requested and verbally consented to the use of a camera due to R1 being a fall risk. The camera was immediately removed from the bedroom. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in the bathrooms.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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 09/20/2022 04:29 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: ADULT CARE OC I	FACILITY NUMBER: 306005939
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.2(a)(1)

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.2, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the facility utilizes a camera in one out of six bedrooms and is not providing R1 a reasonable level of personal privacy which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 09/27/2022
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that cameras will not be used in the resident's bedroom, and the camera was removed during the visit. CLEARED DURING VISIT.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADULT CARE OC I	FACILITY NUMBER: 306005939
	VISIT DATE: 09/20/2022

NARRATIVE

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LPA tested the hot water temperature in the resident bathrooms and the temperature measured at 110.3 degrees Fahrenheit in the Bathroom #1, 116.0 degrees Fahrenheit in Bathroom #2, 115.3 degrees Fahrenheit in Bathroom #3, and 114.0 degrees Fahrenheit in Bathroom #4.

LPA Cho inspected the kitchen along with Licensee Schott and Admin Szalonek. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was charged and serviced on 01/19/2022. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds with Licensee and Administrator. There were three locked sheds that stored holiday decorations, furniture, and gardening supplies. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gates were self-closing and self-latching.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has an evacuation plan in place as well as a plan for isolation. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components, and the facility had sufficient PPEs. Facility has the Infection Control Plan in place, and LPA also discussed Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides an iPad upon request. LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Licensee/Administrator Brian Schott and Administrator Fe Szalonek, and a copy of this report (including LIC809, LIC809-C, LIC809-D, and the appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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