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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006034
Report Date: 09/24/2024
Date Signed: 09/24/2024 11:39:17 AM


Document Has Been Signed on 09/24/2024 11:39 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
ORANGE COUNTY RO, 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:
09/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Mariafe Omosura-House ManagerTIME COMPLETED:
11:53 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin made an unannounced Case Management visit in conjunction with complaint visit 22-AS-20240918082726. LPAs were greeted and granted entry into the facility and initially met with House Manager Mariafe Omosura and explained the reason for the visit.

During the course of the complaint investigation, LPA reviewed Resident 1's (R1's) file and observed that a Pre-Admission Appraisal for R1 was not completed. During today's visit LPAs consulted with Licensee on the importance of doing a Pre-Admission Appraisal prior to accepting a new resident.

Licensee agreed to email the following documents for R1 by close of business on August 25, 2024: Physican Report, Admission agreement, Needs and Services, progress notes and Pre-Admission Appraisal.

Based on today's visit, a deficiency being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with facility representative and a copy was provided as well as Appeal Rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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 09/24/2024 11:39 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
ORANGE COUNTY RO, 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: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87457(a)(c)

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(a)(c)(1)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
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Licensee to complete a preadmission Appraisal and email proof to LPA by POC due date.
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This requirement was not met as evidence by: Based on records reviewed LPA did not observed a Pre-Admission Appraisal for R1. This poses an immediate health, safety or personal rights 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2