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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001960
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:14:23 PM

Document Has Been Signed on 10/24/2024 12:14 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:ECLC - WAKE FOREST VILLAFACILITY NUMBER:
306001960
ADMINISTRATOR/
DIRECTOR:		ANGELITA DAVIDFACILITY TYPE:
740
ADDRESS:233 WAKE FOREST RD.TELEPHONE:
(714) 434-9489
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
10/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Angelita David- Administrator
La Purisima Chang & Maria Berli David- Volunteers
Bernardito David- Caregiver		TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of issuing deficiencies and to follow-up on the Plan of Corrections (POCs) in connection to complaint #22-AS-20240930123543. On October 10, 2024, two Type B citations were issued with the due date of October 18, 2024. The POCs were received via email on October 18, 2024 at 11:36am. Based on the review of the POCs with Administrator (Admin) Angelita David and her family members, the POCs require a revision. The new deadline to complete the POCs with the supporting documents is due on October 31, 2024.

Based on the interviews conducted during the complaint investigation mentioned above, three out of the six staff confirmed medications were being prepared in advance. LPA has reached the decision that Administrator Angelita David is not in good health and incapable of performing all tasks and therefore will be relieved from her duties as an administrator based on the following areas observed on October 3, 2024 and October 10, 2024:
1. medication preparation, storing, and dispensing
2. Admin's lack of judgment and inability to retain information
3. Admin's physical illness that may pose a threat to the well-being of the residents

Therefore, based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met. Deficiencies are being cited on the attached LIC9099D as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted with Administrator Angelita David, Volunteers Maria Berli David, La Purisima Chang, and Caregiver Bernardito David, and a copy of this report including the LIC9099D, and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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Document Has Been Signed on 10/24/2024 12:14 PM - It Cannot Be Edited


Created By: Jessica Cho On 10/24/2024 at 11:17 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: ECLC - WAKE FOREST VILLA
FACILITY NUMBER: 306001960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87465(h)(5)

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87465 Incidental Medical and Dental Care (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 was not met as evidenced by:
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Administrator stated that medications will be prepared for that day effective today and caregivers will receive hands-on medication training as well as provide proof of staff training and an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.
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Based on observation and interviews in three out of six staff confirmed medications were being prepared in advance dispensed in a paper cup which poses a potential Health and Safety Risk to persons in care.
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Type B
11/27/2024
Section Cited
CCR87411(f)

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87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks… Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement was not met as evidenced by:
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Administrator has stated under the presence of 3 family members that she will relieve her duties as an administrator after reaching a decision from one of the following options: employing a new adminstrator, moving forward with a CHOW, or closing the facility. Administrator will provide their decision to LPA in writing by POC due date.
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Based on observations, interviews, and record review, Administrator Angelita David is unable to fulfill their duties/tasks as an administrator.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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