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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005974
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:47:13 AM


Document Has Been Signed on 07/22/2024 11:47 AM - 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:LA HABRA PLAZAFACILITY NUMBER:
306005974
ADMINISTRATOR:DIA, GERALDFACILITY TYPE:
740
ADDRESS:2630 RAINIER WAYTELEPHONE:
(562) 905-0034
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 6DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator, Gerald DiaTIME COMPLETED:
11:50 AM
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On 7/22/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Caregiver, Jan Daniel Massie who was informed of the purpose of the visit. Administrator, Gerald Dia was present and was also informed of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for six (6).

LPA toured the facility with Administrator Dia and observed the facility is made up of a one-story home with four (4) resident bedrooms, two (2) bathrooms, a staff room, kitchen and dining room. During the tour, Administrator Dia tested one (1) of the smoke alarm/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted in the kitchen. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked kitchen cabinet. Resident bedrooms had the required furniture and lighting. The hot water temperature in the resident bathrooms measured at 105- and 109- degrees Fahrenheit. The facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Staff present have a criminal record clearance and valid first aid/CPR certification. During the visit, LPA requested to review resident files and Administrator Dia reported some files were incomplete. Upon review, LPA observed the files for Resident 1, Resident 2, and Resident 3 only contained signed admission agreements and there were no records for Resident 4. Resident 5 and Resident 6 had complete records on file. During the facility's file review, LPA noted the facility is not current with their annual fees. As a result the facility will be cited pursuant to California Code of Regulations, Title 22.

An exit interview was conducted where this report was reviewed and provided to Administrator Dia along with LIC9099-D, Confidential Names List (LIC811), and Appeal Rights.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/22/2024 11:47 AM - 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: LA HABRA PLAZA
FACILITY NUMBER: 306005974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a complete resident record for four (4) out of six (6) residents in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee stated they will complete resident records and submit Proof of Correction (POC) to LPA by close of business on POC due date.
Type B
Section Cited
CCR
87156(a)
(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not ensuring their licensing fees are paid. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee reported they will pay their annual fees online by close of business on 7/24/2024 and submit a copy of the payment receipt as proof of correction to LPA.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2