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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005980
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:03:35 PM


Document Has Been Signed on 05/23/2024 04:03 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 VANNAFACILITY NUMBER:
306005980
ADMINISTRATOR:LESTER DEL ROSARIOFACILITY TYPE:
740
ADDRESS:2438 E PARKSIDE AVETELEPHONE:
(657) 224-9380
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 5DATE:
05/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Karmian Calangi TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Michael Tea are conducting this unannounced case management inspection, in conjunction to Complaint Control #: 22-AS-20240514131824, for the purpose of citing deficiencies.

During today's visit, LPAs conducted a tour of the facility and observed a detached storage building being used as a bedroom for Resident 1 (R1).

LPAs also conducted a resident file review, and per Physician Report dated May 1, 2024, Resident 2 (R2) is currently bedridden. The facility is currently licensed for six non-ambulatory residents.

Based on today's observation, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are also being assessed. See the attached LIC421IM. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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 05/23/2024 04:03 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: CARE VANNA
FACILITY NUMBER: 306005980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
87307(a)(2)(B)

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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 evidence by:
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AD stated the resident would no longer be using the detached building as a bedroom and would return to their assigned bedroom inside the home immediately. AD will provide LPA with picture proof via email by POC date.
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LPAs observed a detached storage building being used as a sleeping room for a resident, which poses an immiedate safety and personal rights risks to person in care.
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Type A
05/24/2024
Section Cited
CCR87202(a)(2)

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Fire Clearance (a) ... Prior to accepting or retaining any of the following types of persons,... licensee shall notify the licensing agency and obtain an appropriate fire clearance approved..(2) Bedridden persons

This requirement is not met as evidence by:
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AD stated they will submit an LIC200, $25 check, and facility sketch to the regional office in person or by mail and proof will be provided to LPA via email by POC date.
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The facility is licensed for 6 non-ambulatory residents and one out of five current facility residents is bedridden, which poses an immediately safety risk to persons in care.
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2