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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006247
Report Date: 04/10/2024
Date Signed: 04/10/2024 09:11:27 AM


Document Has Been Signed on 04/10/2024 09:11 AM - 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:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306006247
ADMINISTRATOR:JUNGE, PAMELAFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE AVENUETELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 17DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Pamela JungeTIME COMPLETED:
09:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240328103849. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Pamela Junge arrived during the visit.

During the course of the complaint investigation, LPA interviewed Facility Administrator and reviewed documents pertinent to the complaint investigation. Resident 1 (R1) admitted into the hospital on 03/16/2024 for a urinary tract infection, skin wound and assessment of ostomy. Per Kaiser Case Manager, R1 was ready to discharge from hospital on 03/19/2024. Case Manager indicated Administrator stated needing to follow up with Licensing for return protocols. Administrator indicated emailing the department for guidance and receiving no response. The department is not aware of any further requests for guidance from the facility. Case Manager states calls were not returned regarding resident discharging and Administrator did not assess resident until 04/06/2024 resulting in continuing hospital charges and a risk of the resident losing Assisted Living Waiver. Conversations with Licensing precipitated the resident being assessed. However, the hospital re-assessment took place 18 days after potential discharge. Department regulations require a re-assessment of resident when a change of condition is present.

Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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 04/10/2024 09:11 AM - 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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306006247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2024
Section Cited
CCR
87463(a)

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The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate... This requirement is not being met as evidenced by:
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Licensee to read regulation an submit a statement of understanding nto LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure R1 was re-assessed for suitability to return to the facility. R1 was re-assessed 18 days after potential discharge. This poses an immediate health and safety risk to residents in care.
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Licensee to submit a written plan on how to address situations that arise at the facility and forward to LPA by POC due date.
Type A
04/11/2024
Section Cited
CCR87405(d)(1)

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The administrator shall have the qualifications specified in Sections 87405(d)... Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not being met as evidenced by:
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Based on interviews conducted, Licensee failed to ensure facility has a qualified administrator. Administrator allowed R1 to remain at hospital for 18 days without following up with licensing or hospital affecting R1's finances and/ or ALW. This poses an immediate health and safety risk.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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