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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002429
Report Date: 02/10/2022
Date Signed: 02/10/2022 02:56:05 PM

Document Has Been Signed on 02/10/2022 02:56 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:FAMILY CARE - PEPITA HOMEFACILITY NUMBER:
306002429
ADMINISTRATOR:RUSSELL VENANZIFACILITY TYPE:
740
ADDRESS:26741 PEPITA DRIVETELEPHONE:
(949) 589-0145
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
02/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ginger Venanzi, Manager
Francesca Mo Deleon and Alfonso Amper, Caregivers		TIME COMPLETED:
12:15 PM
NARRATIVE
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On this day Licensing Program Analysts (LPAs) Kevin Saborit-Guasch, Jerome Haley and Kathrina Chin made an unannounced case management visit in addition to a complaint investigation. LPAs identified themselves and were granted entry by staff. LPAs were met by Ginger Venanzi, Manager who was later called upon by caregiving staff.

Upon entry, the caregivers present did not perform the mandatory COVID-19 screening and temperature check.

At approximately 10:05am, LPAs were shown the location of medication by caregivers. The medication stock present is stored in a locked cabinet to the right of the refrigerator. However, the medication being prepared in advance for the five (5) residents present is located in an unlocked drawer on the other side.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with the caregivers present. A copy of the report and appeal rights were delivered.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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 02/10/2022 02:56 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 02/10/2022 at 11:13 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: FAMILY CARE - PEPITA HOME
FACILITY NUMBER: 306002429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2022
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents in all facilities-(a)(2) To be accorded safe, healthful and comfortable accomodations, furnishings and equipment. The licensee failed to protect the personal rights of residents in care as evidenced by the LPA's observation. This poses an immediate risk to the health and safety of residents in care.
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Licensee will train staff to perform screening before entry as well as ensure appropriate screening is being systematically performed before entry of any visitor into the facility.
Type A
02/10/2022
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons ther than employees responsible for the supervision of the medication. This requirement is not met as evidenced by: LPAs observed 24hr supply of prepared medication being stored in an unlocked drawer.
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The 24hr supply of medication will be stored in the locked cabinet.
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This poses an immediate risk to the health and safety of residents in care.
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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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022


LIC809 (FAS) - (06/04)
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