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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003421
Report Date: 12/27/2024
Date Signed: 12/27/2024 05:00:15 PM

Document Has Been Signed on 12/27/2024 05:00 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:SOUTH HOME CAREFACILITY NUMBER:
306003421
ADMINISTRATOR/
DIRECTOR:		ADELA ALBUFACILITY TYPE:
740
ADDRESS:2779 E. DIANA AVENUETELEPHONE:
(714) 630-5744
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 6DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Adela AlbuTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On December 27, 2024, at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Glenda Awit who called Administrator (AD) Adela Albu by phone. AD Albu informed me that she was ill and would send House Manager (HM) Ciprian Albu to facilitate the tour in her place. HM Albu arrived at the facility around 8:30am and later, AD Adela Albu as well. AD Albu has a current certification posted with an expiration date of November 20, 2025.

The facility is licensed to operate for six (6) non-ambulatory residents and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, (1) staff bedroom, four (4) bathrooms, living room area, dining area, kitchen, an outdoor seating area, and an attached two car garage.

Around 9:00am, LPA Bentley toured inside and outside of the physical plant with HM Albu. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for each resident’s personal belongings was observed. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4, Resident Room 5 and Resident Room 6. Bathrooms were found to be clean and operational. The water temperature measured at 114.6 degrees F to 118.4 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. First aid kit is maintained and contains all the necessary elements.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: SOUTH HOME CARE
FACILITY NUMBER: 306003421
VISIT DATE: 12/27/2024
NARRATIVE
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During the visit, LPA Bentley observed the facility's infection control practices, plan of operation, and visitors policy. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-630-5744) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency water, and additional supplies were stored in the garage. The facility has one (1) fire extinguisher that was observed charged, mounted in the hallway, and serviced on March 8, 2024. Liability Insurance is effective May 23, 2024 and expires on May 23, 2025.

LPA Bentley conducted an audit of six (6) resident files (R1-R6), four (4) staff files (S1-S4), and medication administration review. LPA Bentley conducted two (2) staff interviews and six (6) resident interviews.

Based on observations made during today’s inspection, deficiencies were cited during the time of the visit per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Licensee Adela Albu.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 12/27/2024 05:00 PM - It Cannot Be Edited


Created By: Eboni Bentley On 12/27/2024 at 04:23 PM
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: SOUTH HOME CARE
FACILITY NUMBER: 306003421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


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Page: 10 of 13
Document Has Been Signed on 01/10/2025 04:51 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/10/2025 04:35 PM


Created By: Eboni Bentley On 12/27/2024 at 04:23 PM
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SOUTH HOME CARE
FACILITY NUMBER: 306003421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
THIS WAS AMENDED DUE TO INCOMPLETE DEFICIENT PRACTICE STATEMENT AND MISSING POC.

Based on observation and record review, the licensee has not conducted an emergency disaster drill since August 19, 2024, which poses a potential safety risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Licensee stated they will conduct an emergency disaster drill immediately and submit proof to CCLD via email to
eboni.bentley@dss.ca.gov by January 10, 2025 and will conduct emergency disaster drills quarterly moving forward.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 12/27/2024 05:00 PM - It Cannot Be Edited


Created By: Eboni Bentley On 12/27/2024 at 04:34 PM
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: SOUTH HOME CARE
FACILITY NUMBER: 306003421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 12/27/2024 05:00 PM - It Cannot Be Edited


Created By: Eboni Bentley On 12/27/2024 at 04:34 PM
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: SOUTH HOME CARE
FACILITY NUMBER: 306003421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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