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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006095
Report Date: 02/22/2023
Date Signed: 02/22/2023 05:28:20 PM


Document Has Been Signed on 02/22/2023 05:28 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:EPIC ASSISTANCE CARE HOMEFACILITY NUMBER:
306006095
ADMINISTRATOR:MESDJIAN, LIZAFACILITY TYPE:
740
ADDRESS:26751 CARRETAS DRIVETELEPHONE:
(818) 220-0282
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Liza Mesdjian, administrator (via telephone)TIME COMPLETED:
05:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of documenting deficiencies observed during the initial investigation of the allegations in complaint reference #22-AS-20230217143103. LPA was greeted and granted entry by caregiving staff and spoke with administrator by telephone.

During the health and safety tour of the physical plant, LPA observed that the mounted fire extinguisher had maintenance tags dated August 2021, meaning the required maintenance is outdated by six months.

A review of resident records at the facility showed that four out of the five physician reports indicated a confirmed dementia diagnosis yet were dated by up to two years prior and were therefore outdated per the Title 22 regulations requirements.

The physician report for resident R1 indicates that upon admission, resident was healing from a Stage 3 dermal ulcer. No records of an exemption request to admit a resident with a Prohibited or Restricted Health Condition were found. A Technical Violation advisory is issued to the licensee.

LPA was able to verify administrator's Liza Mesdjian's administrator certificate is current. However, the certificates posted in facility per Title 22 regulations are shown to be outdated and related to individuals no longer associated to the facility. A Technical Assistance advisory note is issued.

Based on observation and records reviewed at the facility, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted via telephone and a copy of the report along with appeal rights was provided and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 02/22/2023 05:28 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: EPIC ASSISTANCE CARE HOME
FACILITY NUMBER: 306006095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
Section Cited

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The California Code of Regulations Title 7 Section 6151(e)(3) indicates that: "Portable fire extinguishers shall be subjected to an annual maintenance check. "



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Licensee will contract a licensed vendor to performed the required annual maintenance on the fire extinguishers present within the physical plant and provide documentation thereof to Licensing Program Analyst before the Plan of Corrections due date.
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This requirement is not met as evidenced by:
Based on observation and record review, fire extinguisher maintenance is out of date since August 2022 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
03/22/2023
Section Cited

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The California Code or Regulations Section 87705(c)(5) on the Care of Persons with Dementia states that: "Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, (...)
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Licensee is to schedule appointments with the primary care physician of all residents with a confirmed dementia diagnosis and submit the updated physician reports resulting from the visits to LPA before the plan of correction's due date.
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This requirement is not met as evidenced by: Based on review, the four resident records observed to include an outdated physician report for residents with confirmed dementia diagnoses, which poses a potential 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: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2