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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006130
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:21:03 PM


Document Has Been Signed on 10/16/2023 04:21 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:CK HOMES / NEPTUNE DRIVEFACILITY NUMBER:
306006130
ADMINISTRATOR:FESTIN, ALEXANDERFACILITY TYPE:
740
ADDRESS:8455 NEPTUNE DRIVETELEPHONE:
(714) 527-6009
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 3DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Olivette Crisostomo, Maxine KniazeffTIME COMPLETED:
04:35 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Olivette Crisostomo and discussed the purpose of the inspection. Administrator (AD) Maxine Kniazeff arrived during the inspection.

LPA reviewed Infection Control requirements. At about 1:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: this is a one-story home. Facility is a 4-bedroom, 2-bathroom, one-story house with attached garage that is being used for storage. LPA observed 2 staff and 3 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 106.5 degrees F in the bathroom near the kitchen and 109 in the bathroom furthest from the kitchen. LPA inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed licensing fees with AD. At about 2:30PM, LPA reviewed 3 resident files and 3 staff files, interviewed 2 residents, inspected medications for 3 residents, and inspected resident money and ledgers for 3 residents.

CONTINUED.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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Document Has Been Signed on 10/16/2023 04:21 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: CK HOMES / NEPTUNE DRIVE

FACILITY NUMBER: 306006130

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee did not ensure 3 out of 3 staff completed the initial 40-hour or annual 20-hour training, which poses a potential health and safety risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee stated they will have all staff trained and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87465(a)(4)


87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee did not ensure R1 received assistance with self-administered medications when R1 missed 1 dose of Propranolol, which poses a potential health risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee stated they will immediately notify R1’s doctor and will provide additional training for staff and submit proof to LPA by POC 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: CK HOMES / NEPTUNE DRIVE
FACILITY NUMBER: 306006130
VISIT DATE: 10/16/2023
NARRATIVE
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During the inspection, LPA and AD observed the following: the staff files for S1, Staff #2 (S2), and Staff #3 (S3) did not contain documentation of the initial 40-hour or annual 20-hour training. The Medication Administration Record for Resident #1 (R1) shows that R1 did not receive the AM 5MG of Propranolol on 10/16/23 and LPA confirmed the pill was still there. The doctor’s instructions indicated the medication should be withheld if R1’s blood pressure was 100/65 or less, but the Blood Pressure Record for 10/16/23 indicates R1’s blood pressure at the time the medication should have been given was 113/82 and did not read 100/65 in any recent readings. During the inspection, AD called the doctor and the doctor stated there should be no issues based on the missed medication.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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