Community Care Licensing

Document Has Been Signed on 05/25/2022 07:56 AM - It Cannot Be Edited

FACILITY NAME:	CAMBRIDGE HOUSE		FACILITY NUMBER:	300611830
ADMINISTRATOR:	EVELYN WALLACE		FACILITY TYPE:	740
ADDRESS:	1895 NORTH CAMBRIDGE		TELEPHONE:	(714) 637-3911
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY: 6		CENSUS: 5	DATE:	05/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Irene Shields- Caregiver, Evelyn Wallace- Administrator		TIME COMPLETED:	12:25 PM

SUPERVISORS NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Andrea Mendivil LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022

Link to Parent Document Below:

FACILITY NAME: CAMBRIDGE HOUSE	FACILITY NUMBER: 300611830
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2022

Type A

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 5 out of 7 beds. LPA observed postural supports without physician's orders which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee to remove postural supports and forward proof to LPA by POC due date.

Type A

Section Cited

CCR

87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed unlocked medications in kitchen cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee corrected during visit.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Andrea Mendivil LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022

Link to Parent Document Below:

FACILITY NAME: CAMBRIDGE HOUSE	FACILITY NUMBER: 300611830
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2022

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed unsecured knives in unlocked kitched drawer which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee to secure knvies and forward proof to LPA by POC due date.

Type A

Section Cited

CCR

87705(f)(2)

The following shall be stored inacessible to residents with Dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed unsecured clearning supplies under kitchen sink and above washer and dryer which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee to secure cleaning supplies and provide proof to LPA by POC due date.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Andrea Mendivil LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022

Link to Parent Document Below:

FACILITY NAME: CAMBRIDGE HOUSE	FACILITY NUMBER: 300611830
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2022

Type A

Section Cited

HSC

1569.695(a)(2)

Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure... including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed lack of emergency water which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee to purchase water and forward proof to LPA by POC due date.

Type A

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed trash cans and discarded furniture which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee to remove trash from side of house and forward proof to LPA by POC due date.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Andrea Mendivil LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022

Link to Parent Document Below:

FACILITY NAME: CAMBRIDGE HOUSE	FACILITY NUMBER: 300611830
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2022

Type A

Section Cited

CCR

87411(g)(2)

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall; (2) request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above. LPA observed an unassociated staff member which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee to fax LIC 9128, LIC 508 and CA driver license to regional office for association by POC due date

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Andrea Mendivil LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022