306005980-9-14-2022-22-AS-ETAA-CJ9TY6-20220914150813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005980
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:08:26 PM

Document Has Been Signed on 09/14/2022 03:08 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:	CARE VANNA		FACILITY NUMBER:	306005980
ADMINISTRATOR:	LESTER DEL ROSARIO		FACILITY TYPE:	740
ADDRESS:	2438 E PARKSIDE AVE		TELEPHONE:	(657) 224-9380
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 4	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:37 PM
MET WITH:	Rio Marie Valencia, Nelson Resso, Karmian Calangi		TIME COMPLETED:	03:20 PM

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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Rio Marie Valencia and Nelson Resoso and stated the purpose of this visit. Administrator Karmian Calangi arrived after the inspection.

The facility is a single-level structure licensed for six non-ambulatory with a hospice waiver for four. This facility offers Residential Care for the Elderly/Dementia.

At about 1:30 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms, one was a shared room and another room was vacant. The facility had a staff room which is inaccessible to residents. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured between 110.1 – 113.9 degrees Fahrenheit. For the exterior portion, furniture was in good repair; and grounds were free of tripping hazards. LPA noticed some wood pieces from a recent construction in the backyard that were not an immediate danger to residents but presented a potential harm to residents. Administrator was made aware and will have items removed. Backyard gate broke during the inspection. Administrator will repair the backyard gate. Facility offers a 2-car garage which is used for storage and had a refrigerator. LPA noticed a nonoperational washer. Administrator is planning to have unused washer removed. Fire alarms, carbon monoxide alarms and auditory exit alarms were tested to be operational. Fire extinguisher was observed. Laundry room was in good repair. Kitchen was in good repair with knifes and cleaning supplies kept locked.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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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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: CARE VANNA	FACILITY NUMBER: 306005980
	VISIT DATE: 09/14/2022

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LPA Tapia viewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiencies were noted in areas observed. Two advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Karmian Calangi and a copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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