306006039-8-30-2024-22-AS-RMRT-D8MQPA-20240830122026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006039
Report Date: 08/30/2024
Date Signed: 08/30/2024 12:25:26 PM

Document Has Been Signed on 08/30/2024 12:25 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	TRADITIONS AT LUCERO WAY		FACILITY NUMBER:	306006039
ADMINISTRATOR:	REYES, LORDELE DE LOS		FACILITY TYPE:	740
ADDRESS:	17801 LUCERO WAY		TELEPHONE:	(714) 769-5858
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	6	CENSUS: 5	DATE:	08/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Lordele De Los Reyes, Administrator		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1. During today’s visit, LPA met with Lordele De Los Reyes, Administrator. The facility is a seven bedroom, single story building with an approved fire clearance of five non-ambulatory residents of which one may be bedridden in bedroom six and four are approved for hospice. The facility currently has a census of five residents in care. During today’s visit, LPA arrived at 8:00am and observed three residents eating breakfast. LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in four of four resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 106.3 and 112.2 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on August 7, 2023. The facility’s last fire drill was conducted on July 7, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed and the First Aid kit is complete. PUB 475 sign is not 20" X 26" regulation size. Chlorox was immediately secured underneath kitchen sink. LPA reviewed three of three staffing and fingerprint records and a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on October 6, 2025. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TRADITIONS AT LUCERO WAY	FACILITY NUMBER: 306006039
	VISIT DATE: 08/30/2024

NARRATIVE

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(Continued from LIC 809)

Upon records review, two of five residents had Admissions Agreements on file. Five of five residents require updated physicians' reports due to clinical diagnosis on file. Two of five residents did not have postural supports orders.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Lordele De Los Reyes, Administrator and a copy of this report was given to the facility along with a copy of the LIC 9102-TV,LIC 858, LIC 859; LIC 809-D and Appeal Rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2024 12:25 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TRADITIONS AT LUCERO WAY	FACILITY NUMBER: 306006039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Licensing Program Analyst observation, interviews and record review the licensee did not comply with the section cited above in one of five residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Administrator will obtain updated physician's report with change to non-ambulatory status since resident was on hospice services and was released from hospice.

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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2024 12:25 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TRADITIONS AT LUCERO WAY	FACILITY NUMBER: 306006039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Licensing Program Analyst (LPA) observations the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	Licensee immediately secured Chlorox bleach in a locked storage area.

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Licensing Program Analyst (LPA) observation, interview and record review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Licensee obtained orders for one of the two postrual supports needed and will obtain physician's orders for full bed rails by POC correction date. Proof of documentation will be sent to LPA via email.

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 Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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