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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001851
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:59:32 PM

Document Has Been Signed on 10/16/2024 12:59 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:KATHRYN JANE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
306001851
ADMINISTRATOR/
DIRECTOR:		ALFONSO/EDILMA AVENDANOFACILITY TYPE:
740
ADDRESS:26861 VIA GRANDETELEPHONE:
(949) 632-3762
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alfonso Avendano, administratorTIME VISIT/
INSPECTION COMPLETED:
01:00 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 administrator Alfonso Avendano after stating the purpose of the visit.

LPA accompanied by administrator conducted a tour of the physical plant and observed the following: the facility is a two-story home with an attached garage. The upper level is only for use by licensee and staff and is kept inaccessible to residents. The facility has five bedrooms including a master bedroom which can be shared and four private bedrooms, There are two bathrooms including the en-suite bath of 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 measured at 107.5F in the shared bathroom. LPA observed all beds have linen and blankets. There are half rails used for postural supports in three of the private bedrooms. Physician orders for all three residents reviewed.

There are currently five residents admitted to the facility, none of which are receiving hospice care. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly and documented. 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 extinguisher present is fully charged and has been maintained in 2024.

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.

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. CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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: KATHRYN JANE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 306001851
VISIT DATE: 10/16/2024
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CONTINUED FROM FORM LIC809

LPA reviewed five resident files along with four staff files. Resident records include all necessary components. Two consultations provided as one admission agreement is observed to be initialed throughout but missing signatures and one physician report update for a resident diagnosed with dementia is still appearing to be pending after being requested in August 2024. 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. Health screenings are on file for all staff members. Facility practices and trains staff on infection control measures, however they are not materialized in an Infection Control Plan. A copy of licensing form LIC9282 provided during the visit along with a consultation from LPA.

Personal rights poster PUB475 is not observed to be posted as the facility only has the poster for the Long-Term Care Ombudsman information posted. A consultation was provided along with an electronic copy of the poster.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Four consultations provided.

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

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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