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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005369
Report Date: 05/15/2025
Date Signed: 05/15/2025 11:58:19 AM

Document Has Been Signed on 05/15/2025 11:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALMOND HOME CAREFACILITY NUMBER:
347005369
ADMINISTRATOR/
DIRECTOR:		ROMENA, ANGELINAFACILITY TYPE:
740
ADDRESS:6701 ALMOND AVENUETELEPHONE:
(916) 817-1668
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
05/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Administrator, Angelina RomenaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst ( LPA ) Talwinder Bains conducted a case management visit to this facility on 05/15/25. LPA met with Administrator Angelina Romena and explained the purpose of today's visit.

The purpose of today's visit is to follow up Title 17 reviews conducted at this facility by Alta California Regional Center (ACRC) on 04/01/25. Facility Action Report (FAR) was generated by ACRC from the Title 17 reviews. Community Care Licensing Division (CCLD) received a copy of the FAR and it was noted in the FAR the facility was cited for violations that are in both Title 17 and Title 22. The visit today is to address the issues found in the FAR that apply to Title 22.
Based on the FAR report, the facility violated the following Title 22 violations:
For resident, R1;
· Hydrocortisone, Mupirocin, and Acetaminophen has no PRN form.
· Risperidone dosage does not match Rx prescription on CSMDR.
For resident, R2;
· Lorazepam PRN medication is missing from the facility.
· Missing signature for Lorazepam for medication administration on 4/1/25.
For resident, R3;
· Senna 8.6 mg is missing from PRN authorization letter.
· Melatonin 3 mg is the current Rx prescription but PRN authorization letter states 1 mg.
Staff Qualification/ Training:
· Staff, S1, First Aid was found expired on 04/01/25
· Staff, S2, has not completed 12 CE units within the 12 months from date of hire. Per Facility Plan of Operation, "the Administrator shall conduct monthly in-service training's in the home”.
· S2 has missing certificates for monthly in-service training's.
Based on the above, deficiencies are cited pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809D. Exit interview conducted and copy of report ,LIC809G and appeal rights provided.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700
DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/15/2025 11:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HOME CARE
FACILITY NUMBER: 347005369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2025
Section Cited
CCR
80075(b)(4)

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80075-Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(4) If the client's physician has stated in writing that the client is able to determine ...this requirement is not as evidenced by;
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Licensee/Administrator shall send letter of understanding of this regulation and shall conduct staff training for medications management. All POC documents are due by 06/05/25.
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Facility did not followed doctor's orders for medications managament for residents, R1,R2,R3 which poses potential health and safety risks to residents in care.
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Type B
06/05/2025
Section Cited
CCR80075(7)

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80075-Health Related Services
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications .....this requirement is not met as evidenced by;
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Licensee/Administrator shall send letter of understanding of this regulation and shall conduct staff training for medications management for proper records keeping. All POC documents are due by 06/05/25.
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Record review indicated record keeping errors for CSMR/MAR records for residents, R1,R2,R3 which poses potential health and safety risks to residents in care.
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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.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2025 11:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HOME CARE
FACILITY NUMBER: 347005369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2025
Section Cited
CCR
80075(b)

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80075-Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications....this requirement is not as evidenced by;
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Licensee/Administrator shall send letter of understanding of this regulation and shall conduct staff training for medications management. All POC documents are due by 05/16/25.
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Based on record review from the facility, it was determined that facility did not administer the medication for residents, R2 and R3 as ordered by their physician. This poses an immediate health and safety risk to residents in care.
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Type B
05/22/2025
Section Cited
CCR80075(f)

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80075-Health Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.....this requirement is not met as evidenced by;
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Licensee/Administrator shall send letter of understanding of this regulation. All staff should have active CPR/First Aid certificate.
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Record review on 04/01/25 indicated that staff, S1 has expired CPR/First Aid certificate which poses potential health and safety risks for residents in care.
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Staff, S1 has active CPR/First Aid certificate as of so this citation has been cleared during this visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025

LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/15/2025 11:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HOME CARE
FACILITY NUMBER: 347005369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2025
Section Cited
CCR
80022(k)

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80022-Plan of Operation-(k)-The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so........this requirement is not as evidenced by;
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Licensee/Administrator shall send letter of understanding of this regulation. Facility shall fulfill all requirements for staff training per facility's operational plan and submit proof to department. All POC documents are due by 06/05/25.
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Record review on 04/01/25 indicated that facility did not comply with annual training requirements per facility's operational plan which poses potential health and safety risks to residents in care.
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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.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025

LIC809 (FAS) - (06/04)
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