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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006034
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:37:07 AM


Document Has Been Signed on 10/04/2022 10:37 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PHAMILY HOME ELDERLY CARE 2FACILITY NUMBER:
306006034
ADMINISTRATOR:PHAM, CHARLESFACILITY TYPE:
740
ADDRESS:16652 HUGGINS AVETELEPHONE:
(657) 724-9930
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 5DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Fe Osumra- Caregiver TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Andrea Mendivil and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Maria Fe Osumra and explained the reason for the visit. Administrator Charles Pham arrived at 10:08 AM.

At 9:11 AM, LPAs toured the facility with Caregiver Maria Fe Osumra. Facility is 4 resident bedrooms, 2 resident bathrooms, and 1 staff bathroom, one story home with an attached garage. Facility has 5 residents present during today's visit. LPAs observed a screening and sanitizing station at entrance of the facility. LPAs observed residents relaxing in their room and living room watching TV. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. LPAs observed unlocked chemicals under kitchen and restrooms sinks. Facility has 2 refrigerators with ample food supply. At 9:20 AM LPAs observed facility has 72-Hour emergency food and water supply. Facility has a secured location for resident medication and files. LPAs toured the outside grounds and observed outside visitation area. Exit gates are unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPAs observed a 4 weeks supply of PPE. LPAs reviewed all residents’ files and all contained required documentation including updated emergency information.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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 3


Document Has Been Signed on 10/04/2022 10:37 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: PHAMILY HOME ELDERLY CARE 2
FACILITY NUMBER: 306006034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 resident files as they did not contain physician's order for postural supports which poses a potential personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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Licensee to remove rails and obtain physician's order for postural supports.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/04/2022 10:37 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: PHAMILY HOME ELDERLY CARE 2
FACILITY NUMBER: 306006034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inacessible to residents with Dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee did not secure cleaning chemicals/razors which poses immediate health and safety risk to persons in care.
POC Due Date: 10/04/2022
Plan of Correction
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Licensee corrected during visit.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3