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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006280
Report Date: 04/10/2024
Date Signed: 04/10/2024 04:13:35 PM


Document Has Been Signed on 04/10/2024 04:13 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:SHASTA RESIDENTIAL CAREFACILITY NUMBER:
306006280
ADMINISTRATOR:DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:16274 SHASTA STTELEPHONE:
(714) 300-4540
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Jason "Jae" Flake, CaregiverTIME COMPLETED:
04:20 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a subsequent unannounced visit after delivering findings for complaint control # 22-AS-20240404121611.
LPA Quiroz was greeted by Caregiver 1 (CG1) and met with Caregiver 2 (CG2) and discussed purpose of today's visit. LPA Quiroz attempted to call Administrator (AD) Kevin Dinh multiple times with no response or call back. Caregivers in care indicated "There's a person in charge when Kevin is away on vacations her name is Janice. LPA Quiroz called and spoke to AD Janice Jabonero who indicated "I didn't know he was on vacations. He asked me in February to cover during his absence but didn't tell me the dates. " (SEE LIC 809-D)
On or about 2:35pm while conducting tour and interviewing Resident 3, LPA Quiroz observed centrally stored medication and vitamins stored on shelves in staff bedroom with door unlocked readily available for residents in care.
On or about 2:53am while conducting inspection tour of living room and kitchen area, LPA Quiroz observed loose screen door in living room area, as evidenced by Caregiver 2 requiring to pull it out from frame and reinstalling it back in order to open screen door per Resident 1's request. On or about 2:40pm, while inspecting garage area, LPA Quiroz observed staff pulling on garage door stating "It's hard to open and close, we had to use both of our hands to open and close but now we just use one but pull hard." (SEE LIC 809-D)
During today's inspection visit, while conducting tour of the facility and conducting interviews for complaint control #22-AS-20240404121611, the following deficiencies were observed and are being cited via this case management deficiency.
  • 87303(a)-Maintenance and Operation
  • 87405(a)-Administrator - Qualifications and Duties
The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Caregivers on site, and a copy of this report, 809-D Page, Appeal Rights and LIC 811 were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
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 04:13 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: SHASTA RESIDENTIAL CARE
FACILITY NUMBER: 306006280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2024
Section Cited
CCR
87405(a)

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87405(a)Administrator - Qualifications and Duties:(a)All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the CONT...
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AD Kevin Dinh will read and understand CCR 87405, submit proof of understanding of CCR 87405, LIC 500 and designation of responsibility LIC 308 by POC due date of 4/17/2024.
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management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable...This requirement was not met as evidenced by:
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Caregivers indicated AD Kevin Dinh on vacation providing first name and phone number of designated person in charge during his absence. CCLD was not notified of AD Dinh's absence. At 3:45pm, AD Jabonero indicated no knowledge of L/AD Kevin Dinh being on vacation. This poses an immediate risk to residents in care.
Type B
04/17/2024
Section Cited
CCR87303(a)

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Maintenance and Operation-87303(a): (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by, LPA Quiroz observed On or about 2:35pm while conducting tour and interviewing Resident 3, LPA Quiroz observed centrally stored CONT...
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medication and vitamins stored on shelves in staff bedroom with door unlocked readily available for residents in care.On or about 2:53am while conducting inspection tour of living room and kitchen area, LPA Quiroz observed loose screen door in living room area and staff struggling to open and close
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door leading to garage door area. This poses a potential risk to residents in care.
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: Rosie QuirozTELEPHONE: (559) 753-4610
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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