306006189-12-13-2022-22-AS-SHAD-CM42BY-20221213161556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006189
Report Date: 12/13/2022
Date Signed: 12/13/2022 04:16:20 PM

Document Has Been Signed on 12/13/2022 04:16 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:	KAEGO'S RICHMAN GARDENS		FACILITY NUMBER:	306006189
ADMINISTRATOR:	HARVEY, LUPE		FACILITY TYPE:	740
ADDRESS:	317 N. RICHMAN GARDENS		TELEPHONE:	(213) 478-0460
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	26	CENSUS: 17	DATE:	12/13/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Rosalba Maldonado, Wendy Cruz Andrade		TIME COMPLETED:	04:30 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) Sean Haddad conducted this unannounced inspection for the purpose of conducting a post licensing inspection. LPA met with Staff #1 (S1) Rosalba Maldonado, discussed the purpose of the inspection, and toured the facility. Facility Manager (FM) Wendy Cruz Andrade arrived during the inspection. Administrator (AD) Lupe Harvey appeared via telephone. LPA provided a copy of Entrance Checklist Residential Care Facilities for the Elderly (LIC9242). During the inspection, LPA and FM observed the following: Structure. This is a small commercial facility. Facility is a 13-bedroom, 5-bathroom, multi-building small commercial facility with detached garages that are being used for storage. There is a large back yard with a patio cover for the residents. Facility telephone number is (714) 733-7518. Resident Bedrooms. The 13 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 106.7 to 117 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed, including the smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in closets. Medication cabinet is locked in the locked medication room. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. LPA reviewed resident and staff files. Fire clearance was approved by Fullerton Fire Department Inspector Peggy Castenada on 06/09/2022. Backyard. Backyard exit gate is operational and kept locked. Backyard has shaded area for outdoor activities and sufficient seating for residents.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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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Document Has Been Signed on 12/13/2022 04:16 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: KAEGO'S RICHMAN GARDENS	FACILITY NUMBER: 306006189
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2022

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
1 2 3 4	Based on records, the licensee did not ensure 4 out of 5 staff files contained documentation of staff training, which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/04/2023
	Plan of Correction
1 2 3 4	Licensee stated they will document training for all staff, provide any missing training, and provide proof to LPA by POC due date.

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records, the licensee did not ensure 4 out of 5 resident files reviewed contained a current appraisal, which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/04/2023
	Plan of Correction
1 2 3 4	Licensee stated they will gather all appraisals, conduct additional appraisals as necessary, and provide 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 Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: KAEGO'S RICHMAN GARDENS	FACILITY NUMBER: 306006189
	VISIT DATE: 12/13/2022

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During the inspection, LPA observed there were 4 staff present, wearing PPE. LPA observed 17 residents were present. LPA conducted health and safety checks on the residents, confirmed the residents were doing well, and observed no health and safety issues. LPA observed COVID+ residents isolated in isolation rooms. LPA inspected common areas, resident rooms, kitchen, and garage and observed they were clean and organized, and found no health and safety issues. 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. LPA observed hallways and walkways were free of obstruction.

During the inspection, LPA and FM reviewed 5 staff files and 5 resident files and observed the following: 4 out of 5 staff files reviewed did not contain documentation of staff training; 4 out of 5 resident files reviewed did not contain a current appraisal.

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 Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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