306006006-8-22-2022-22-AS-JCHO-CHJVGE-20220822162526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006006
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:25:33 PM

Document Has Been Signed on 08/22/2022 04:25 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:	HEYDAY SENIOR LIVING OF COSTA MESA		FACILITY NUMBER:	306006006
ADMINISTRATOR:	ALIM, REA BADILLO		FACILITY TYPE:	740
ADDRESS:	2750 LORENZO AVE		TELEPHONE:	(562) 303-0130
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 6	DATE:	08/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Rea Alim, Jean Andrade		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 08/22/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Heyday Senior Living of Costa Mesa. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 1:59pm, LPA Cho was allowed entry into the facility and met with Caregiver Jean Andrade after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Rolando Flores was also present at this time. Administrator (Admin) Rea Badillo Alim arrived at the facility at 3:10pm. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) was observed in the required sizing. The facility is licensed for six non-ambulatory residents and has a hospice waiver for two. There are currently four residents living in the facility of which three are receiving hospice care. The facility is operating beyond the approved hospice waiver specified on the license. The Administrator's Certificate for Rea Alim expires on 11/25/2022 and 10/19/2022 for Jerome Alim. Around 2:40pm, LPA Cho conducted a tour of the physical plant along with Caregiver Jean Andrade. The single story home consists of three resident bedrooms with two resident bathrooms. There is one staff bedroom. The facility also has a living room, dining area, kitchen, and an attached two car garage. The facility has two cameras located in the garage and dining area. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and a non-skid mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperatures measured at 110.1 degrees Fahrenheit in the Bathroom #1 and 110.4 degrees Fahrenheit in Bathroom #2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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: HEYDAY SENIOR LIVING OF COSTA MESA	FACILITY NUMBER: 306006006
	VISIT DATE: 08/22/2022

NARRATIVE

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LPA Cho inspected the kitchen along with Caregiver Andrade. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gate was self-closing and self-latching. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility does have back-up emergency food and water supply. The First Aid Kit met all the required components including the first aid manual, and the facility had sufficient PPEs.

No resident or staff files were reviewed at the time of this visit. LPA reviewed the COVID-19 mitigation plan of the facility as well as 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 does have an existing internet service and provides a smart phone and iPad upon request.

LPA provided the following guidance: to operate within the approved hospice waiver as specified on the license and to submit the Infection Control Plan (LIC9282) pertaining to Monkeypox by August 29, 2022. In addition, LPA discussed 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 Administrator Rea Alim, and a copy of this report (including LIC809, LIC809C, LIC809D, 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: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2022 04:25 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: HEYDAY SENIOR LIVING OF COSTA MESA	FACILITY NUMBER: 306006006
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(a)

87204 Limitations- Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, and interviews of Administrator and care staff, the facility is operating beyond the maximum number of persons who may receive hospice servies at one time. Facility has an approved hospice waiver for two but three hospice residents were noted at this time which poses a potential Health, Safety, and Personal Rights risk to persons in care. the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/24/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit an increase of hospice waiver request and to forward proof to LPA by POC due date.

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: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC809 (FAS) - (06/04)

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