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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006247
Report Date: 11/25/2024
Date Signed: 11/25/2024 03:29:45 PM

Document Has Been Signed on 11/25/2024 03:29 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:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306006247
ADMINISTRATOR/
DIRECTOR:		JUNGE, PAMELAFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE AVENUETELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 30CENSUS: 22DATE:
11/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Pamela Junge - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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LPAs Dwayne Mason Jr and Nancy Guillen arrived at the facility for the purpose of conducting a Case Management visit to issue deficiencies. LPAs were greeted and granted entry by facility staff. LPAs met with Administrator, AD, Pamela Junge and explained the purpose of the visit.

On 11/22/2024, LPAs issued three deficiencies as part of the facility's annual inspection. Due to a final printing error, one of the deficiency pages was deleted from the Licensing database.

LPAs issued a deficiency for a medication error - Incidental Medical and Dental - Type B: 87465(c)(2)
LPAs issued a deficiency for part of the facility not being safe and in good repair - Maintenance and Operation - Type B: 87303(a)

Based on today's visit, two deficiencies are being issued. LPAs reviewed this report with facility staff. A copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 11/25/2024 03:29 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/25/2024 at 02:52 PM
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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306006247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2024
Section Cited
CCR
87303(a)

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Maintenance and Operation: 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times.

The Licensee did not comply with the section cited above due to the presence of an accessible collapsed fence on the
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Administrator stated they will repair the fence and ensure the side of the house is inaccessible to residents in care by the assigned plan of corrections due date of December 9, 2024.
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side of the house. This poses a potential safety risk to persons in care.
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Type B
12/09/2024
Section Cited
CCR87465(c)(2)

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Incidental Medical and Dental Care - 87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions.

The Licensee did not comply with the section cited above due to the presence
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Administrator stated they will conduct an in-service training regarding Medication Administration and Documentation by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics
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of a missed medication dose in one resident's medication. LPAs observed the dose was signed off on the Medication Administration Record, indicating it was administered.
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covered. AD stated they will email LPA all documentation for this training by the assigned Plan of Correction due date of December 9, 2024.
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: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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