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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003482
Report Date: 01/24/2023
Date Signed: 01/24/2023 03:23:43 PM

Document Has Been Signed on 01/24/2023 03:23 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:KAMSTRA CARE HOMEFACILITY NUMBER:
306003482
ADMINISTRATOR:OSVALDO SANTA ANAFACILITY TYPE:
740
ADDRESS:5265 CANTERBURY DRIVETELEPHONE:
(562) 637-3392
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6CENSUS: 6DATE:
01/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Runette Catibog - Administrator TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced Case Management visit to Kamstra Care Home. LPA Velazquez met with Administrator Runette Catibog. During the complaint investigation visit with Complaint Number: 22-AS-20220923152100, LPA Velazquez questioned ADMIN Catibog regarding the facility's lack of submission of an LIC 624 Unusual Incident/Injury Report for R2's hospitalization on September 22, 2022. ADMIN Catibog confirmed that an LIC 624 was not submitted to Licensing pursuant to statute and regulation.


LPA Velazquez printed Title 22 Regulation Section 87211 Reporting Requirements and provided Administrator Catibog with consultation regarding adherence to this regulation. LPA Velazquez also advised ADMIN Catibog to participate in the Provider Informational Calls as well as staying abreast with the Provider Information Notices (PINs) which can be found on the CCLD website.


Deficiencies cited under California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator Runette Catibog and a copy of this report along with the appeal rights, LIC 811, LIC 9098 and were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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 01/24/2023 03:23 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 01/24/2023 at 03:04 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: KAMSTRA CARE HOME
FACILITY NUMBER: 306003482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited
CCR
87211(a)(1)(A-D)

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Reporting Requirements. Each Licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement is not met as evidenced by: based on record review and interview the Licensee did not submit an LIC 624 for R2's hospitalization.
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The Licensee to ensure written reports are submitted to the Department pursuant to this regulation. The Licensee to provide LPA a written statement indicating they have read this section of Title 22 regulation and how exactly they intend to adhere to it by POC due date.



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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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
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