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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001028
Report Date: 07/16/2021
Date Signed: 07/16/2021 02:41:25 PM

Document Has Been Signed on 07/16/2021 02:41 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOOD SAMARITAN IIFACILITY NUMBER:
306001028
ADMINISTRATOR:CAMBIO, SUSAN & LEOFACILITY TYPE:
740
ADDRESS:26852 LA SIERRATELEPHONE:
(949) 367-1228
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Leo Cambio and Susan CambioTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Mayra Fernandez and explained the reason for the visit. Licensees Leo and Susan Cambio arrived during visit.

At 11:10 AM, LPA toured the facility with Licensee Cambio. Facility has 5 residents during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily. Facility has covid precaution postings as well as all required department postings. Facility has completed the mitigation plan and LPA approved the plan during the visit. LPA observed adequate emergency food supply as well as the first aid kit which contained all required items. Facility has all items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation areas. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files and all contained emergency information. LPA observed six out of six physician reports are outdated. All six residents have a Dementia diagnosis.

LPA consulted with Licensee regarding the importance of documenting temperatures taken daily as well as having ample emergency water supply in the facility at all times.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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 07/16/2021 02:41 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 07/16/2021 at 11:49 AM
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: GOOD SAMARITAN II
FACILITY NUMBER: 306001028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)


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 six out of six physician reports are outdated. All six residents are diagnosed with Dementia and have physician reports out of date. This poses a potential health and safety risk to persons in care.
POC Due Date: 07/30/2021
Plan of Correction
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Licensee to obtain updated physician reports and forward proof to LPA by 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021


LIC809 (FAS) - (06/04)
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