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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603092
Report Date: 06/17/2023
Date Signed: 06/17/2023 02:59:52 PM


Document Has Been Signed on 06/17/2023 02:59 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:WHITE ORCHID GUEST HOMEFACILITY NUMBER:
374603092
ADMINISTRATOR:ESTEPA, STANFACILITY TYPE:
740
ADDRESS:978 WEST 2ND AVETELEPHONE:
(760) 737-6030
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:5CENSUS: 2DATE:
06/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Stan Estepa, LicenseeTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility to conduct an annual inspection. LPA met with caregiver, Jocelyn Estepa. Licensee Stan Estepa arrived shortly. LPA explained the purpose of the visit and was granted entry into the facility. The facility is licensed for five (5) elderly residents, in which two (2) residents may be non-ambulatory. The facility has a hospice waiver for two residents. Current census is two(2). The facility is a one story, five (5) bedroom two (2) bathroom home. The facility was inspected inside and out. LPA conducted staff and client interviews.

The facility appears clean and free of odors. Staff present have criminal record clearances and are appropriately associated to the facility. Client bedrooms are clean and appropriately furnished. Food supplies are sufficient. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Water temperature was measured and deemed appropriate. Furniture in the facility is in good repair. Outdoor space is free of hazards.



LPA inspected the staff and client records. Staff files had the required documentation including First Aid Certifications and training documents. Client records had required documentation and files were up to date.

LPA inspected medications and during the inspection, the LPA observed the following deficiencies:

-The facility had medication pills that were pre-prepared and stored in a cup - not in its original container.
-The facility had a PRN medication on hand, constipation cream - not listed on the Medical Administration Record (MAR) .

Based on observations made by LPA, the facility was cited and deficiencies noted on LIC809D. An exit interview was conducted with the Caregiver and Licensee, and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2023
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 06/17/2023 02:59 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: WHITE ORCHID GUEST HOME
FACILITY NUMBER: 374603092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 1 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee will conduct a refresher training on proper dispursement of medication. Licensee will email documentation of training to LPA.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee will update medication list. Licensee will provide refresher training on medication record keeping. Licensee will email documents of updated medication list and proof of refresher training.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2023
LIC809 (FAS) - (06/04)
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