306003482-9-20-2024-22-AS-ARJR-D9ANMM-20240920103523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003482
Report Date: 09/20/2024
Date Signed: 09/20/2024 10:35:27 AM

Document Has Been Signed on 09/20/2024 10:35 AM - 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:	KAMSTRA CARE HOME		FACILITY NUMBER:	306003482
ADMINISTRATOR/ DIRECTOR:	OSVALDO SANTA ANA		FACILITY TYPE:	740
ADDRESS:	5265 CANTERBURY DRIVE		TELEPHONE:	(562) 637-3392
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY: 6		CENSUS: 5	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:20 AM
MET WITH:	Rosemarie Balacuit-Caregiver, Runette Catibog-Administrator		TIME VISIT/ INSPECTION COMPLETED:	10:49 AM

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Rosemarie Balacuit. Administrator (AD) Runette Catibog arrived shortly after.

For today’s visit, LPA observed a total of five residents in care and two staff members on duty.

LPA observed the Administrator's Certificate for facility AD Runette Catibog which expires on October 26, 2025.

LPA Ramirez toured the interior and exterior portions of the facility with AD Catibog. The facility is a single level structure and is licensed for six non-ambulatory residents, of which six may be on hospice and zero bedridden. There are a total of five bedrooms, of which four are resident bedrooms, and one private bedroom for staff. LPA Ramirez 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. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 106.1-107.9 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 and located by the dining room.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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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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: KAMSTRA CARE HOME	FACILITY NUMBER: 306003482
	VISIT DATE: 09/20/2024

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LPA observed the emergency disaster and evacuation plan which is located by dining room. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

During today's visit LPA observed residents watching television and/or relaxing in their bedroom.

LPA reviewed five resident files and three staff files. LPA interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA Ramirez advised AD Catibog to use the general email address:

CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Catibog.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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