306006050-9-16-2022-22-AS-KSGH-CJBRAB-20220916125051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006050
Report Date: 09/16/2022
Date Signed: 09/16/2022 12:51:08 PM

Document Has Been Signed on 09/16/2022 12:51 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:	MIA RESIDENCE		FACILITY NUMBER:	306006050
ADMINISTRATOR:	ADOLFO, JED		FACILITY TYPE:	740
ADDRESS:	25475 ADRIANA ST		TELEPHONE:	(949) 305-5259
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Cristopher Ventura, caregiver Jocelyn Ventura, caregiver Giannina Adolfo, Administrator		TIME COMPLETED:	01:05 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 09/16/2022 at 11:00am, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Alvaro Ramirez made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPAs were greeted and granted entry by Cristopher Ventura and Jocelyn Ventura, caregivers and explained the purpose of the visit. Facility administrator Giannina Adolfo was notified by telephone but was unable to assist with the visit in person due to flu-like symptoms. At approximately 11:15am, LPAs accompanied by caregiver toured the physical plant of the facility. There are currently six (6) residents in care, two (2) of which are receiving hospice care. Residents are observed relaxing in the common area or in their respective bedrooms and appear clean and well taken care of. The six individual bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Full rails are observed in the bedroom of resident R1 who is no longer on hospice. A Technical Violation is issued as full rails are a prohibited form of postural support for non-hospice residents. Sharp instruments are kept in a locked cabinet under the kitchen sink, along with cleaning supplies. The centrally stored medication is located in a standalone cabinet with double doors and a magnetic lock for each door. Caregiving staff is observed opening the unlocked left door multiple times before the magnetic lock gets readjusted during the visit. A 30-day supply of medication is observed. LPA observed a sufficient supply of food and water present. LPA observed the facility has COVID-19 Precautions posters and all required department postings. Staff present is adequately cleared and associated in Guardian. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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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Document Has Been Signed on 09/16/2022 12:51 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: MIA RESIDENCE	FACILITY NUMBER: 306006050
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

CCR Section 87465(h)(2) indicates that: "Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement is not met as evidenced by: Durting the facility inspection, the medication central storage was observed to be left unlocked by facility staff. Cabinet was locked during the visit.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Licensee will provide an updated in-service training to caregiving staff on the required locking of the medication central storage and provide documentation of the training to Department staff.

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: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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: MIA RESIDENCE	FACILITY NUMBER: 306006050
	VISIT DATE: 09/16/2022

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CONTINUED FROM FORM LIC809

LPA and caregivertoured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present for the enjoyment of residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Violation is issued regarding the full rails. This report was reviewed with facility administrator over the phone and a copy of this report and appeal rights was provided and left at facility. Administrator gave permission to caregiving staff present to sign report on her behalf.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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