<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006050
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:32:48 PM

Document Has Been Signed on 11/22/2024 01:32 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:MIA RESIDENCEFACILITY NUMBER:
306006050
ADMINISTRATOR/
DIRECTOR:		ADOLFO, JEDFACILITY TYPE:
740
ADDRESS:25475 ADRIANA STTELEPHONE:
(949) 305-5259
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Giannina Adolfo, administratorTIME VISIT/
INSPECTION COMPLETED:
01:40 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 this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry by facility caregivers after introducing themselves and stating the purpose of the visit. Administrator Giannina Adolfo was notified by telephone and arriver later to assist with the visit.

LPAs accompanied by facility staff conducted a tour of the physical plant and observed the following: the facility is a one-story home with an attached garage. The facility has six private bedrooms. All resident bedrooms have the required furnishings. LPAs observed all beds have linen and blankets. There are half rails used for postural support in one of the private bedrooms and full rails on another. Physician orders for both were reviewed, along with the hospice plan of care for the resident with full rails. There are three bathrooms, two of which are en-suite. All bathrooms are observed to be equipped with grab bars and slip mats. The shared bathroom accessed through the hallway is observed to have a dirty floor mat with deposit as well as rust stains on the wall below the hand rail. The HVAC intake on the ceiling across from the bathroom is also observed to be covered in dust. Type B citation issued. Bathrooms faucets and toilets are operational. Water temperature was measured at 114.4F and 113.5F in two of the three bathrooms.

There are currently five residents admitted to the facility, two of which are receiving hospice care. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly and documented. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are fully charged and have been maintained in 2024.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 6
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: MIA RESIDENCE
FACILITY NUMBER: 306006050
VISIT DATE: 11/22/2024
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
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC809
There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The routes of egress are free of obstructions.

Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders. One medication's supply is observed to be exhausted for one resident, however staff interviewed confirmed that the previous bedtime dose had been dispensed the night before and that the pharmacy had confirmed a pending delivery for the day of the visit. Consultation provided.

LPAs reviewed five resident files along with the staff records for the two staff members present at the time of the visit. Resident records include all necessary components. One admission agreement is absent from the resident's records but a signed copy was provided to licensing staff by administrator during the visit. Technical Assistance consultation provided. One resident has been admitted to the hospital on the day of the visit. Review of the resident's records indicate a primary diagnosis of Parkinson's and diabetes, while prescriptions show the presence of insulin injections via pens. The latest physician report for the resident in question indicates that the resident is unable to self-administer insulin and glucose level monitoring. Facility staff is stated to be doing hand-over-hand for diabetes management. Type B deficiency cited.

One consultation provided on the topic of activities as more adequate stimulation could have been provided during the present visit.

All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training and CPR training verified to be up to date. Health screenings are on file for all staff members. Infection Control Plan present and reviewed.

Based on the observations made during today’s inspection, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Three consultations provided.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/22/2024 01:32 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 11/22/2024 at 01:00 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: MIA RESIDENCE
FACILITY NUMBER: 306006050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation made during the tour of the physical plan, the licensee did not comply with the section cited above as one dirty anti-slip mat, along with rust stains on a shower wall and dust on the HVAC intake were seen to be present. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
1
2
3
4
Licensee will clean and/or replace the dirty elements and provide documentation to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one resident is reviewed to have a diabetes diagnosis and is assessed to be unable to self-administer their treatment, with injections conducted hand-over-hand with facility staff. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
1
2
3
4
Prior to readmission of the resident with a diabetes diagnosis, facility staff will ensure that Home Health additional visits are scheduled in order to delegate diabetes management and injections to an appropriately skilled professional, proof of which will be provided to LPA before the plan of corrections 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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6