306006062-10-14-2022-22-AS-KSGH-CK7SVK-20221014141254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006062
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:13:23 PM

Document Has Been Signed on 10/14/2022 02:13 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:	JADE GUEST HOME		FACILITY NUMBER:	306006062
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2710 N. BERKELEY ST		TELEPHONE:	(714) 507-8040
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 6	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Leodigario Garais, caregiver Brevet Dao, Administrator (via phone)		TIME COMPLETED:	02:00 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 10/14/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by Leodigario Garais, caregiver after explaining the purpose of the visit. Administrator Brevet Dao was notified by phone, but was not available to assist with the visit in person. Infection Control measures were reviewed over the phone. Administrator agreed to review the final report over the phone as well and authorized her staff to sign on her behalf. At approximately 11:15am, LPA accompanied by caregiver toured the physical plant of the facility. There are currently six (6) residents in care, three (3) of which are receiving hospice care. Residents are observed relaxing in their respective bedrooms or in the common areas. One resident is observed to not be dressed and only able to cover his chest up with a bedsheet which is a deficiency in regards to their dignity and personal rights. More residents are observed in beds equipped with postural supports than there are residents stated on hospice, which prompted LPA to request the residents records on file to search for the required doctor's orders. Facility staff was only able to present resident files for 3 residents out of the 6 observed at the facility. Caregiver indicates that the three other residents were admitted this week and that the administrator is working on organizing the files. Bathrooms are equipped with grab bars and slip mats. The main bathroom for use by the residents has a dirty floor, which LPA documented in photographs. An sufficient supply of linen is observed. Sharp instruments are kept unsecured in a kitchen drawer without a functioning lock. Cleaning supplies are store unsecure under the kitchen sink as well as in the laundry closet which is not equipped with a lock either. The centrally stored medication is located in a closet in the hall leading to the bedrooms. While a padlock can be used, the closet was unlocked at the time of the visit. 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: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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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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: JADE GUEST HOME	FACILITY NUMBER: 306006062
	VISIT DATE: 10/14/2022

NARRATIVE

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CONTINUED FROM FORM LIC809

LPA observed a sufficient supply of food and water present. Caregiver indicates that the next market day is on Saturday. The fire extinguisher present is charged and has been recently maintained. Staff member S1 is adequately cleared and associated in Guardian, however the other caregiver present (S2) is not cleared nor associated.

LPA and caregiver toured the outside of the facility. While the exit routes are mainly clear, there is a large quantity of clutter present such as broken television sets or bags full of cans to be recycled. LPA provides consultation that exterior spaces need to be cleared of excessive debris. Outdoor furniture and a shaded area are present in the backyard for the enjoyment of residents and visitors. The entrance gates on both sides of the house are self-latching. There are no bodies of water on the premises.

LPA observed a bedroom used by caregiving staff separated from the living room and entertainment area with a curtain suspended in the door frame. Vitamins or dietary supplements are seen in the unsecured room on the night stand next to the bed.

Based on the observations made during today’s visit, six (6) deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Four Technical Assistance Advisories are also issued. This report was reviewed over the phone with facility administrator and signed by authorized facility representative. A copy of this report along with appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2022 02:13 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: JADE GUEST HOME	FACILITY NUMBER: 306006062
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

The California Code of Regulations Section 87465(h)(2) relative to Incidental Medical and Dental Care 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: LPA observed that staff present had left the door to the medication closet unlocked while conducting the inspection visit. Caregiver states that they only lock the medication "when they sleep".
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews conducted during the visit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2022
	Plan of Correction
1 2 3 4	Licensee will ensure that centrally stored medication remain locked and secure at all times.

Type A

Section Cited

CCR

87705(f)

The California Code of Regulations Section 87705(f) relative to the Care of Persons with Dementia indicates that: "The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) 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: LPA observed sharp instruments, cleanings solutions, insecticide and/or rodenticide and nutritional supplements left unsecured throughout the physical plant.
	Deficient Practice Statement
1 2 3 4	Based on observation made during the inspection visit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2022
	Plan of Correction
1 2 3 4	Licensee will ensure the safe and secure storage of all the identified objects and substances by the Plan of Correction 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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2022 02:13 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: JADE GUEST HOME	FACILITY NUMBER: 306006062
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

The California Code of Regulations Section 87506(a) relative to Resident Records indicates that "The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff." This requirement is not met as evidenced by: Licensing staff requested residents files during the inspection visit. Caregiver was only able to provide three files out of six residents observed at the facility.
	Deficient Practice Statement
1 2 3 4	Based on 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: 10/28/2022
	Plan of Correction
1 2 3 4	Licensee will ensure that a complete and current record is present and available for each individual in care before the Plan of Corrections due date.

Type B

Section Cited

CCR

87303(a)(1)

The California Code of Regulations Section 87303(a)(1) pertaining to Maintenance and Operation states that: "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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition." This requirement is not met as evidenced by: LPA observed footsteps marking the floor throughout the resident bathroom. The commode in the visitor bathroom is also noted to be non-functional.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2022
	Plan of Correction
1 2 3 4	Licensee will ensure that the floor in the two bathroonms is kept clean, safe and sanitary and that the two commodes are functional 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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

Page: 4 of 9

Document Has Been Signed on 10/14/2022 02:13 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: JADE GUEST HOME	FACILITY NUMBER: 306006062
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(1)

The California Code of Regulations Section 87468.1(a)(1) relative to Personal Rights of Residents in All Facilities indicates that: "Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons." This requirement is not met as evidenced by: LPA observed one resident with no items of clothing on the top part of their body, using a bedsheet to cover up during the inspection visit.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2022
	Plan of Correction
1 2 3 4	By the plan of corrections due date, the licensee will ensure that the right to dignity of all the individuals in care at the facility are accorded.

Type A

Section Cited

CCR

87355(e)

The California Code of Regulations Section 87355(e) on Criminal Record Clearance states that "All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working (...) in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or Request a transfer of a criminal record clearance as specified in Section 87355(c) or Request and be approved for a transfer of a criminal record exemption. This requirement is not met as evidenced by: One staff member present is neither cleared nor associated to the facility in Guardian.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Licensee will immediately remove staff member from the facility and ensure that they are not scheduled to work at the facility until they have received the required background clearance and been associated to the facility in Guardian.

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: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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