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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006189
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:05:26 PM


Document Has Been Signed on 08/13/2024 03:05 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 GARDENSFACILITY NUMBER:
306006189
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:317 N. RICHMAN GARDENSTELEPHONE:
(714) 733-7518
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:26CENSUS: 25DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Wendy CruzTIME COMPLETED:
03:20 PM
NARRATIVE
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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 Administrator (AD) Wendy Cruz and discussed the purpose of the inspection.

LPA reviewed Infection Control requirements. At about 12:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a small commercial facility. Facility is a 13-bedroom, 5-bathroom, 4-building small commercial facility with multiple storage areas, a kitchen, a dining room, a medication room, and multiple common areas. There is a large back yard with a patio cover for the residents. The entire facility is a memory care unit with a delayed egress alarmed exit at the front gate. Resident Bedrooms: the 9 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 9 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 126, 138, 85, and 109 degrees F in the Tea Rose, Jasmine, Calla Lilly, and Apple Blossom buildings, respectively. 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. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 1:30PM, LPA reviewed 5 resident files and 5 staff files, interviewed 5 residents and 5 staff, and inspected medications for 5 residents. Facility does not handle resident money.

CONTINUED
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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 08/13/2024 03:05 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: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


87303 Maintenance and Operation (e) … (2) … Hot water temperature controls shall be maintained … to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the hot water tested at 126, 138, 85, and 109 degrees F in the Tea Rose, Jasmine Calla Lilly, and Apple Blossom buildings, respectively, which poses an immediate safety risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Licensee stated they will adjust the temperature and submit a protocol to regularly test water temperatures to LPA by POC due date.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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: 08/13/2024
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During the inspection, LPA and AD observed the following: based on observation, the hot water tested at 126, 138, 85, and 109 degrees F in the Tea Rose, Jasmine, Calla Lilly, and Apple Blossom buildings, respectively.

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: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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