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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006344
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:06:09 PM


Document Has Been Signed on 07/22/2024 03:06 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:COGIR OF BREAFACILITY NUMBER:
306006344
ADMINISTRATOR:FAYE, SAMUELFACILITY TYPE:
740
ADDRESS:700 MADISON WAYTELEPHONE:
(714) 681-0105
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:110CENSUS: 45DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Miriam ImTIME COMPLETED:
03:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with the Health Services Director Miriam Im and explained the reason for the visit. The facility is a two-story building with 82 resident rooms. The building has a central courtyard with outdoor shaded seating area. The facility has 2 dining rooms, a theater, fitness room and an activity room. Facility has a capacity of 110 non-ambulatory of which 12 may be bedridden and a hospice waiver for 12. LPA and the Health Services Director toured the facility. LPA observed the See Something Say Something poster posted next to the main entry door of the facility. There are 2 stairways which are both outside. LPA observed an evacuation chair at the top of each stairway. LPA observed the kitchen is clean and organized. The refrigerator and freezer are maintained at the required temperatures. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The fire extinguishers in the kitchen are fully charged. LPA observed carbon monoxide detectors on each floor of the facility. All of the carbon monoxide detectors tested operational. The facility's fire protection equipment was inspected on November 21, 2023, no deficiencies noted. The delayed egress exit doors on the first floor are operational. LPA and Health Services Director toured the resident rooms. LPA observed that all the rooms inspected (6) had the required furnishings and bed linens. Hot water measured from 114.9 to 117.6 degrees Fahrenheit in all 6 six rooms. No obstacles or hazards observed inside or outside of the facility. The activity room has games and puzzles for residents. The theater has a large screen TV for residents to watch movies or TV. LPA reviewed 6 resident files and medications, no discrepancies observed. LPA reviewed 5 staff files. All staff members interviewed and encountered were background cleared and associated to the facility. LPA observed Staff 1 did not have the required initial training of 20 hours in their first 4 weeks of employment. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/22/2024 03:06 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: COGIR OF BREA
FACILITY NUMBER: 306006344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)(a)
(a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment.

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 in 1 out of 5 staff members, staff 1 did not complete the required 20 hours of training within the first four weeks of employment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee agrees to have staff 1 trained in compliance with the regulation above and to submit proof of training to the LPA by the POC due date.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2