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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006206
Report Date: 12/18/2024
Date Signed: 12/18/2024 12:05:45 PM

Document Has Been Signed on 12/18/2024 12:05 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELIZABETH HOMES / STANTONFACILITY NUMBER:
306006206
ADMINISTRATOR/
DIRECTOR:		KNIAZEFF, MAXINEFACILITY TYPE:
735
ADDRESS:7161 STANTON AVETELEPHONE:
(714) 994-1176
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 4DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:11 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by facility staff. LPA met with Maxine Kniazeff, Assistant Administrator and explained the purpose of the inspection.

The facility is one-story building with 6 client rooms, 2 client bathrooms, kitchen, dining room, living room, two offices, staff bathroom, family room, backyard and 2-car garage. All client rooms had the required elements, including bed, chair, closet space and ample lighting. LPA observed the facility to be in good repair. LPA observed one exit gate that are self-latching and unlocked. Facility has toxins, chemicals and cleaning supplies locked in a cabinet in the laundry area. LPA observed an uncovered bowl of meat in a refrigerator accessible to clients. A deficiency is being issued. Facility staff immediately covered the bowl with saran wrap and wrote "For Staff" on the wrap. LPA observed sharps to be locked in a drawer in the kitchen. Restrooms are stocked with soap and paper towels. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPA observed the fire extinguishers are full as indicated by the arrow pointing in the green zone on the meter. LPA observed the service tags on the extinguishers stating they were serviced on October 2, 2024. LPA reviewed 7 staff files and 4 client files. LPA reviewed the P&I and medication for all clients. Based on medication review, LPA observed one prescription for one client to have no label. A deficiency is being issued. LPA conducted interviews with 2 staff. Clients present were non-verbal and unable to be interviewed by LPA. LPA observed the facility to have the necessary postings including a menu and activity calendar. LPA observed facility has games, electronics, art supplies and exercise equipment for client use.

Based on today's inspection, two deficiencies are being issued. An exit interview was conducted and a copy of this report, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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 12/18/2024 12:05 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 12/18/2024 at 11:37 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: ELIZABETH HOMES / STANTON
FACILITY NUMBER: 306006206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

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 due to the presence of an uncovered bowl of meat in a refrigerator accessible to clients. This poses a potential safety risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Facility staff stated they will conduct an in-service training on food storage. Staff stated they will document the individuals attending the training, topics covered and date/time of the location. Staff stated they will email LPA the documentation by the assigned POC due date.
Type B
Section Cited
CCR
80075(b)(6)(D)
(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above due to the absence of a label on a client's prescribed medication bottle. This poses a potential health risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Facility stated they would acquire a label for the prescription from the pharmacy for the medication. Facility staff also stated they will conduct an in-service training regarding Medication storage, administration and records. Staff stated they will document the individuals attending the training, topics covered and date/time of the location. Staff stated they will email LPA the documentation by the assigned 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
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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