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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003807
Report Date: 12/30/2024
Date Signed: 12/30/2024 03:50:30 PM

Document Has Been Signed on 12/30/2024 03:50 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:CHATEAU FRANCESCAFACILITY NUMBER:
306003807
ADMINISTRATOR/
DIRECTOR:		MARIZA OLIVAFACILITY TYPE:
740
ADDRESS:33821 VIA CASCADATELEPHONE:
(949) 234-0559
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 5DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Ronlado MarianoTIME VISIT/
INSPECTION COMPLETED:
04:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. Facility is a licensed RCFE with a capacity of 6 non-ambulatory residents with a hospice waiver for 4. The facility is a single story 5 bedroom (1 bedroom is for staff) house with 2 bathrooms, living room, dining room, family room, kitchen and a 2 car garage. LPA observed the See Something, Say Something sign (PUB 475) posted next to the front door. The fireplace in the living room is screened. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the 4 burner gas cook top lights unassisted. LPA observed knives and medications are kept locked in a kitchen cabinet. LPA observed all resident rooms had the required furnishings. Smoke detectors/carbon monoxide detectors tested operational. LPA observed in bathroom 1 in the hallway, the window glass is broken and the window is taped. LPA observed in bathroom 1 the vanity lights did not work. The hot water measured 111.0 degrees Fahrenheit in bathroom 1. LPA observed two holes in the hallway wall that are taped up with plastic. Staff could not explain the nature of the repair being conducted with the hallway wall. LPA observed clean linens in the hallway closet. The garage is kept locked and used for storage. The garage has emergency food and water and cleaning supplies. LPA toured the backyard. No bodies of water observed. Both exit gates are operational. There is a shaded seating area for residents to sit outside. The last fire drill was conducted on October 14, 2024. LPA reviewed 5 resident records and medications. LPA observed 1 out 5 residents did not have a current appraisal (Resident 3), no other discrepancies noted . LPA reviewed 2 staff files. Both staff members are background cleared and associated to the facility. Both staff members have current CPR/First Aid training. Staff 2 has an Administrator's certificate and documented proof of training. Staff 1 has no documented training. Staff verified the facility has internet service but no dedicated internet device for resident use. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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Document Has Been Signed on 12/30/2024 03:50 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/30/2024 at 03:17 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: CHATEAU FRANCESCA
FACILITY NUMBER: 306003807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
...This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, Staff 1 has no documented training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee agrees to have Staff 1 trained in compliance with the regulation above and to forward proof to LPA by the POC due date
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed the bathroom window in bathroom 1 is broken, the vanity lights in bathroom 1 do not work and there are 2 holes in the hallway wall, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee agrees to fix or replace the broken window in bathroom 1, to fix the broken vanity lights in bathroom 1 and to fix and repair the holes in the hallway wall and to send proof of repair to the LPA by the POC due date.
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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/30/2024 03:50 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/30/2024 at 03:35 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: CHATEAU FRANCESCA
FACILITY NUMBER: 306003807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 in out 5 residents, Resident 3 did not have a current appraisal which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Licensee agrees to complete an appraisal for Resident 3 and to submit the completed appraisal by the POC due date to the LPA.

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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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