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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006313
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:40:00 PM


Document Has Been Signed on 08/15/2024 02:40 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:FOUNTAIN OF YOUTH SENIOR LIVINGFACILITY NUMBER:
306006313
ADMINISTRATOR:JERRAR, MOE A.FACILITY TYPE:
740
ADDRESS:525 N CAROUSEL PLACETELEPHONE:
(657) 208-3199
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Brianna BernalTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit for the purpose of conducting an Annual Required inspection. LPA met with House Manager Brianna Bernal and purpose of visit was shared. Licensee/Administrator was not available.

Facility is a 6-bedroom, 3-bathroom, 1-story house with an outside shed on the side of the kitchen that is used for storage. There is also a shed on the other side of the facility with staff's personal belongings, table, and a bed. Facility has a working telephone land line. There were 6 Residents of which one is receiving Hospice Care and three staff present during the visit. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Backyard has a covered patio for outdoor activities and sufficient seating for residents and visitors. Bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were observed to be clean and have a supply of soap and paper towels. Hot water temperature was within regulatory requirements. Linen and hygiene supplies were stocked. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted. Stove burners, dishwasher, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the residents. Medication was observed locked in a kitchen cabinet. Medications reviewed appear to have been dispensed accurately.
LPA reviewed 6 resident files and 4 staff files. LPA interviewed residents and staff. LPA confirmed Administrator's certificate expired on 07/20/2024. Administrator Moe Jerrar has submitted documentation to renew Certificate.
Based on observations made during today's visit, the following deficiencies are being cited. Advisory Note was also issued. An exit interview was conducted with House Manager and a copy of this report was sent to email on file.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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 08/15/2024 02:40 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: FOUNTAIN OF YOUTH SENIOR LIVING

FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
CRIMINAL RECORD CLEARANCE. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, record review, the licensee did not comply with the section cited above in that Reliever, Guadalupe Meza Lopez, was hired approximately on 8/12/2024, has no fingerprint clearance & is not associated with the facility. Hiring staff without fingerprint clearance & association with the facility poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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House Manager understand that Staff Meza Lopez cannot work or be present at the facility until staff has fingerprint clearance & association is completed. Since staff has not been fingerprinted & cleared & was working as a Reliever since 8/12/2024, a Civil Penalty of $100.00 per day is being assessed.
Type A
Section Cited
CCR
87307(a)(2)(B)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.

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 in that there was a beds, dresser, table, and personal belongings in an outside structure that is to be used for storage. This poses a potential health, safety or personal rights risk to staff and persons in care. Facility did not obtain a Fire Clearance approval to use the shed for staff sleeping quarters. This poses an immediate Health & Safety risk to the staff and residents in care.
POC Due Date: 08/16/2024
Plan of Correction
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Facility will immediately stop staff from using the shed as a bedroom. Will remove all personal belongings from shed. Facility will not allow any individual to reside in a structure that is not fire cleared for occupancy. Shed shall only be used for storage unless a city code approval and fire clearance approval is obtained.
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: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2024 02:40 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: FOUNTAIN OF YOUTH SENIOR LIVING

FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above in that Resident 4 has a full bed rail and is not receiving Hospice care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Staff to remove the full bed rail . Facility to obtain a physician's order for half-bed rail, if there is a need and keep in file. Facility to provide POC by 8/16/2024.
Type B
Section Cited
HSC
1569.625
Personnel Requirenments - Staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training which consists of 40 hours of training for new staff or 20 hrs annually for staff in specific areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above in that 4 out of 4 had no proof of training or needed their annual training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee to ensure that Staff receive specific training as stated in Health & Safety 1569.625. Staff to read regulation cited and submit understanding of regulation to LPA on or before 08/30/2024. LPA will retrun to review staff files.
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: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/15/2024 02:40 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: FOUNTAIN OF YOUTH SENIOR LIVING

FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements-General. Staff shall receive First Aid training from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record reviews, the licensee did not comply with the section cited above in that 4 out of 4 staff did not have First Aid and CPR training in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Facility will have Staff take classes on First Aid and CPR and will submit to Licensing a copjy of the certiifcates on or before 08/30/2024.

Type B
Section Cited
CCR
87458(a)
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in that 3 of 6 files reviewed, 2 were missing Physician's Report and one need to be updated due to diagnosis, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Facility to obtain and/or update Physician's Reports and place in each respective file.
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: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4