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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003527
Report Date: 10/31/2024
Date Signed: 10/31/2024 11:51:05 AM

Document Has Been Signed on 10/31/2024 11:51 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:YORBA LINDA SENIOR CAREFACILITY NUMBER:
306003527
ADMINISTRATOR/
DIRECTOR:		CHRISTOPHER CURTISFACILITY TYPE:
740
ADDRESS:4451 ACORN COURTTELEPHONE:
(714) 993-0449
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 4DATE:
10/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Caregiver Noel OrielTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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
On October 31, 2024, around 8:30am Licensing Program Analyst (LPA) Edward Kim arrived to complete the required 1-year annual visit that was started September 16, 2024. LPA Kim was greeted and granted entry by Caregiver (CG) Eliza Oriel. Administrator (AD) Christopher Curtis arrived to the facility at 8:50 am. AD Christopher Curtis could not stay for the entire visit and said CG Noel Oriel will assist with the visit and can sign the report on their behalf.

During the visit, LPA conducted a full audit of all resident files, and all resident medications. The smoke detectors and carbon monoxide detectors were operable. LPA Kim conducted two resident interviews and one staff interview.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. A technical violation was assessed during the visit.

An exit interview was conducted, and a copy of this report and the appeal rights were provided to Caregiver Noel Oriel.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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 3
Document Has Been Signed on 10/31/2024 11:23 AM - It Cannot Be Edited


Created By: Edward Kim On 10/31/2024 at 10:50 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: YORBA LINDA SENIOR CARE
FACILITY NUMBER: 306003527

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed and interviewed the Administrator who stated there are 3 residents under hospice and the faciility is licensed for a Hospice waiver for 2. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
Licensee states they will request an increase in hospice waiver for the facility and send a copy of the completed hospice waiver request to CCLD via email to edward.kim@dss.ca.gov by POC due date November 14, 2024.
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in one out of four residents. LPA observed R2 who is diagnosed with Dementia but the current Physician's Report is from June 22, 2023 and the Reapprasial was not avaialble at the time of the visit. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
1
2
3
4
Licensee states they will provide a current Physician's Report and Reppraisal of R2 to CCLD via email to edward.kim@dss.ca.gov by POC due date November 14, 2024.
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:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3