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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000635
Report Date: 10/07/2024
Date Signed: 10/07/2024 02:59:57 PM

Document Has Been Signed on 10/07/2024 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAMEO HOMES - MARINERSFACILITY NUMBER:
306000635
ADMINISTRATOR/
DIRECTOR:		ROSE MANABAT PALMAFACILITY TYPE:
740
ADDRESS:1411 MARINERS DRIVETELEPHONE:
(949) 515-8645
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 5DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Lise Brick, licensee
Rose Joven, administrator		TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Licensee Lise Brick and Administrator Rose Joven arrived later to assist with the visit.

During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with five private bedrooms in addition to a staff room. There are three bathrooms throughout the facility including an en-suite in the master bedroom. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. Bathrooms faucets and toilets are operational. Water temperature was initially measured to be over 130F and was adjusted during the visit. A type B citation was issued during the visit and cleared as the water was eventually measured to be within acceptable range. LPA observed all beds have linen and blankets. Postural supports with corresponding orders are observed in four out of five rooms visited. Appropriate physician orders are on file for all four.

There are currently five residents admitted to the facility, one of which is receiving hospice care. One of the residents is not present during the visit as they are away overnight. Hospice plan of care reviewed for one resident. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed. Drills are conducted quarterly and documented as required by regulations. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are fully charged and have been maintained in 2024.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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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: CAMEO HOMES - MARINERS
FACILITY NUMBER: 306000635
VISIT DATE: 10/07/2024
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CONTINUED FROM FORM LIC809

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The routes of egress are free of obstructions. There is an adequately fenced swimming pool present on the premises. Backyard and pool area appear clean and well maintained.

Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed five resident files including one hospice file along with staff files for the two caregivers on shift at the time of the visit. Resident records include all necessary components. All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training and CPR training verified to be up to date.

Based on the observations made during today’s inspection, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Three consultations provided.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2024 02:59 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 10/07/2024 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMEO HOMES - MARINERS
FACILITY NUMBER: 306000635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the visit, water temperature was measured to be over 130F in the kitchen as well as in the bathrooms used for personal grooming which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Facility staff adjusted the water heater setting during the visit and were able to bring the water temperature within the 105-120F range as required by Title 22 regulations. Citation cleared during the visit.
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 Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


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