<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003406
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:05:08 PM

Document Has Been Signed on 05/09/2024 12:05 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:ORANGE MANOR, THEFACILITY NUMBER:
306003406
ADMINISTRATOR/
DIRECTOR:		AIDA MARTIRESFACILITY TYPE:
740
ADDRESS:1824 NORTH SHAFFER ST.TELEPHONE:
(714) 283-2474
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 5DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Facility Administrator - Aida MartiresTIME VISIT/
INSPECTION COMPLETED:
12:27 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Celine De Perio and Michael Tea conducted an unannounced required annual inspection. LPAs explained reason for visit and was greeted and granted entry by facility administrator (AD) Aida Martires. The PUB475 "See Something, Say Something" poster was observed in the living room. LPAs observed the Administrator's Certificate for Aida Martires, which expires on 3/23/25.

LPAs toured the interior and exterior portions of the facility with AD. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 6 may be on hospice. For this visit, there are a total of 5 residents in care, of which 4 on hospice. There are a total of 5 bedrooms, of which 4 are private resident rooms, 1 shared resident room, and 1 room designated for staff. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPAs observed that there is a basement that is used as a facility office.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 4 restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature was measured to be at 106.8 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the living room.



LPAs observed the emergency disaster and evacuation plan, which is located in a cabinet in the kitchen. Facility had back-up emergency food and water supply, located in the kitchen, in the garage, and in the basement. LPAs observed that First Aid Kit had all the required components. Medications were locked in a kitchen cabinet. Toxins were also observed to be locked and inaccessible to residents.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: ORANGE MANOR, THE
FACILITY NUMBER: 306003406
VISIT DATE: 05/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For the exterior portion, LPAs observed patio furniture under shading, and the grounds were free of any hazards. There are 3 gates in the backyard, which were self-closing and self-latching. No bodies of water were observed.

For today's visit deficiencies were issued.

LPAs conducted an exit interview was conducted with AD Martires.

A copy of this report was provided and explained.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/09/2024 12:05 PM - It Cannot Be Edited


Created By: Celine DePerio On 05/09/2024 at 11:47 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: ORANGE MANOR, THE
FACILITY NUMBER: 306003406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(3)
ยง1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling

(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record reviews, and interviews, the licensee did not comply with the section cited above. It was observed that 3 out of 3 staff members had expired First-Aid and CPR certifications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
1
2
3
4
As a plan of correction (POC), licensee will schedule First-Aid and CPR classes for the 3 staff members, and will provide proof to assigned LPA on or by 5/9/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4