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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006115
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:26:49 PM

Document Has Been Signed on 03/20/2024 12:26 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:T3 ADULT CARE RESIDENTIAL CAREFACILITY NUMBER:
306006115
ADMINISTRATOR:WILLIAMS, GLORIAFACILITY TYPE:
735
ADDRESS:1726 SOUTH LATUS PLACETELEPHONE:
(714) 797-6057
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 4DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Thien LuuTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to T3 Adult Residential Care. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and explained the reason for the visit. Facility is licensed for 4 ambulatory clients and the facility currently has 4 clients. Max Nguyen has an Administrator Certificate expiring on 01/17/2026. Administrator Tien Luu arrived during the visit. Upon entry into the facility, LPA observed pre-poured medications unsecured in dining area.

LPA Lyman along with Administrator Tien Luu toured the facility at 9:43 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of four client bedrooms, one shared hall bathroom, client restroom, staff restroom, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 10:00 AM, LPA observed unsecured vitamins in Client 1's (C1) room. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 114 and 114.9 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. LPA observed a locked storage area for cleaning supplies in the laundry room. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for clients. Exit gates are unlocked and operational. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan as well as infection control plan during the visit. Plans are thorough and complete. Facility provided documentation of last fire drill conducted on 12/28/2023. Facility provides activities in the form of movies and outings in the community. At 10:20 AM, LPA reviewed four client files and three staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. CONTINUED ON LIC 9099C DATED 03/20/2024

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: T3 ADULT CARE RESIDENTIAL CARE
FACILITY NUMBER: 306006115
VISIT DATE: 03/20/2024
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Staff files reviewed contained required documentation of training and criminal record clearance. At 11:00 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are being administered per physician order.



Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.


SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
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Document Has Been Signed on 03/20/2024 12:26 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/20/2024 at 11:39 AM
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: T3 ADULT CARE RESIDENTIAL CARE
FACILITY NUMBER: 306006115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured pre-poured medications in the dining area. Four out of four clients cannot manage nor store medications per physician reports which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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Licensee to submit a statement of understanding of the regulation and forward to LPA by POC due date. Medications were secured during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


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