306006095-3-30-2023-22-AS-LMAZ-CQEU8D-20230330152119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006095
Report Date: 03/30/2023
Date Signed: 03/30/2023 08:49:56 PM

Document Has Been Signed on 03/30/2023 08:49 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:	EPIC ASSISTANCE CARE HOME		FACILITY NUMBER:	306006095
ADMINISTRATOR:	MESDJIAN, LIZA		FACILITY TYPE:	740
ADDRESS:	26751 CARRETAS DRIVE		TELEPHONE:	(818) 220-0282
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Liza Mesdjian		TIME COMPLETED:	01:45 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) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year Annual inspection. Upon arrival LPA was greeted and granted entry by Carestaff AnnaMarie and Darwin Gamboa. LPA began inspection with introduction and visit purpose. There are currently 6 Residents residing and present at the facility. Facility currently has 4 Residents receiving Hospice care. Administrator (AD) Liza Mesdjian arrived shortly after. LPA along with Carestaff AnnaMarie conducted a tour of the inside and outside of the facility. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the Residents. Lighting is sufficient for safety and comfort. The facility is a one story, 7 bedroom, 8 bathroom home with a dining room, living room, kitchen, and attached garage. There is a back yard with a patio table and chairs and a canopy for shade. Resident bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. Hot water in bathrooms was within regulatory requirements. Linen and hygiene supplies were stocked in hallway closets. Emergency Phone Numbers and Exit Plan were reviewed. Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Emergency food and water supply is available. Smoke and Carbon Monoxide detectors are centrally wired and were found to be operational. Fire Extinguishers were charged and mounted, last serviced on 02/28/2023. Stove burners, microwave, dishwasher, washer, and dryer are operational. There is a locked location for chemicals and sharps in the kitchen. Laundry is done in the laundry room. The garage is used for storage. Medications are centrally stored and locked in a locked kitchen cabinet. LPA reviewed medication for Residents. Medications reviewed appear to have been dispensed accurately. (see LIC809C)

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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: EPIC ASSISTANCE CARE HOME	FACILITY NUMBER: 306006095
	VISIT DATE: 03/30/2023

NARRATIVE

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First-Aid Kit and Activity Supplies, were observed and available. There is a working land line at the facility. The LIC610, Emergency Disaster Plan is posted. Facility’s licensing fees are fully paid.

Indoor passageways are free of obstruction. LPA observed a washer, recliner, old mattress outside in backyard. Exit gate is self latching.

LPA reviewed 6 Resident files. Files showed that three of six Physician's Reports indicated a confirmed Dementia diagnosis yet were dated by up to two years prior. LPA reviewed 2 Carestaff files. Facility staff do not have documented required training. Administrator Certificate expires on 07/29/2024.

LPA interviewed Residents and Carestaff.

Based on the information received during this visit today in the areas reviewed, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/30/2023 08:49 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: EPIC ASSISTANCE CARE HOME	FACILITY NUMBER: 306006095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

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, (...) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviewed, the licensee did not comply with the section cited above in that three out of six Physician's Reports indicated a confirmed Dementia diagnosis yet were dated by up to two years prior, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee is to schedule appointments with Primary Care physicians of residents with a confirmed Dementia diagnosis and submit the updated Physician's Reports to LPA on or before POC due date of 4/14/2023. Civil Penalty - Repeat Violation is being assessed.

Type B

Section Cited

CCR

87412(c)

Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Licensee failed to ensure verification of staff training is maintained. Two out of two staff do not have documentation of required training. This poses a potential health and safety risk to residents in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all staff training is up to date and verification is maintained in staff file. Licensee to forward proof to LPA by POC due date OF 04/14/2023

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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