306006013-8-31-2023-22-AS-SHAD-CV8VME-20230831163327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006013
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:33:33 PM

Document Has Been Signed on 08/31/2023 04:33 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:	ALOHA CARE FACILITY		FACILITY NUMBER:	306006013
ADMINISTRATOR:	IGARTA, ALICIA		FACILITY TYPE:	735
ADDRESS:	890 WHITEBOOK DR		TELEPHONE:	(562) 690-9509
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY: 4		CENSUS: 4	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Juan Bernal, Alicia Igarta		TIME COMPLETED:	04:45 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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Juan Bernal and discussed the purpose of the inspection. Administrator (AD) Alicia Igarta arrived during the inspection. LPA reviewed Infection Control requirements. At about 1:45PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 2 staff and 3 clients present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 115.7 degrees F in the hallway bathroom 119.3 in the single bedroom bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in a lockbox. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. AD stated they paid the facility’s licensing fees. At about 2:30PM, LPA reviewed 4 client files and 5 staff files, interviewed 3 clients and 2 staff, inspected medications for 4 clients, and inspected client money and ledgers for 4 clients.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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 08/31/2023 04:33 PM - It Cannot Be Edited

Created By: Sean Haddad On 08/31/2023 at 04:16 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALOHA CARE FACILITY	FACILITY NUMBER: 306006013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(b)

Client Medical Assessments

(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the facility did not have physician's reports for 2 out of 4 clients, which poses a potential health and safety risk to person in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Licensee stated they will obtain physician's reports for these 2 clients and submit copies of all 4 physician's reports to LPA by POC due date.

Type B

Section Cited

CCR

80075(b)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records, the licensee did not ensure 1 resident recieved 1 dose (possibly 2 doses) of resperidone, which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Licensee stated they will retrain staff on medication administration and submit proof to LPA by POC due date.

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 Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ALOHA CARE FACILITY	FACILITY NUMBER: 306006013
	VISIT DATE: 08/31/2023

NARRATIVE

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During the inspection, LPA and AD observed the following: the facility did not have physician's reports for 2 out of 4 clients; the licensee did not ensure Resident #1 (R1) received 1 dose of risperidone on 08/23/23 when the medication administration record states it was provided but the pill was still there and possibly also on 08/30/23 when the pill was still there but the medication administration record was blank and did not state if the medication was refused.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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