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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006247
Report Date: 11/22/2024
Date Signed: 11/22/2024 04:47:30 PM

Document Has Been Signed on 11/22/2024 04:47 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:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Pamela Junge - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Fred Arias arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Pamela Junge, Administrator and explained the purpose of the inspection.

The facility is one-story building with 15 resident rooms,8 bathrooms, kitchen, dining room, living room, medication room, staff break room, front patio and 2-car garage. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed the fence on one side of the house has fallen over. LPAs determined this side of the house is accessible to residents even though it is unsafe for residents due to the collapsed fence. One deficiency is being issued. Facility has toxins, chemicals and cleaning supplies locked in the garage and a kitchen cabinet. Restrooms are stocked with soap and paper towels. Hot water measured between 105 and 120 degrees F. LPAs observed facility has emergency food and water supply as well as additional emergency supplies. LPAs reviewed six staff files and ten resident files. LPAs conducted interviews with six residents and three staff. LPAs reviewed medication. Based on medication review, LPAs determined a resident missed a medication dose, however, facility staff signed the Medication Administration Record indicating the medication was taken at the appropriate time. One deficiency is being issued. Based on record review, LPA determined the facility did not report an incident that occurred on 8/21/2024 to Licensing. One deficiency is being issued.

Based on today's inspection, three 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: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 11/22/2024 04:47 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/22/2024 at 04:06 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: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)(D)
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The Licensee did not report Resident 1's elopement or hospitalization due to elopement. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator stated they will conduct an in-service training regarding Reporting Requirements 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 covered. AD stated they will email LPA all documentation for this training by the assigned Plan of Correction due date of December 6, 2024.
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 Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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