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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003850
Report Date: 03/01/2023
Date Signed: 03/01/2023 02:58:51 PM

Document Has Been Signed on 03/01/2023 02:58 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:WHISPERING OAKS - WAVERLYFACILITY NUMBER:
306003850
ADMINISTRATOR:IMELDA C. CAROFACILITY TYPE:
740
ADDRESS:14782 WAVERLY LANETELEPHONE:
(714) 931-1945
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 6CENSUS: 5DATE:
03/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Gasparina Lofranco - CaregiverTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Whispering Oaks - Waverly. LPA Velazquez was allowed entry into the facility and met with Caregiver Gasparina Lofranco. While at the facility LPA Velazquez spoke with Administrator Imelda Caro and explained the purpose of today's visit. The purpose of today's visit was to conduct a Case Management - Deficiencies visit due the Licensee's failure to completely correct citations issued during the complaint investigation with Complaint Control Number: 22-AS-20201006154007. The original Plan of Correction (POC) due date was January 21, 2023.



Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Caregiver Gasparina Lofranco and a copy of this report along with the Appeal Rights and LIC 9098 were provided at the time of this visit. A POC correction letter was provided at the time of this visit for one citation that was cleared.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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 03/01/2023 02:58 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 03/01/2023 at 02:48 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: WHISPERING OAKS - WAVERLY
FACILITY NUMBER: 306003850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/02/2023
Section Cited
HSC
1569.652(c)

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Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually
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Licensee to refund R1's family the $600 that is still due via Cashier's check and mailed overnight to name and address provided. Licensee to provide written proof to LPA by POC due date.
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responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement was not met as evidenced by: based on interview and record review the licensee failed to provide R1's family with a refund pursuant to statute and regulation. This poses a potential risk to the health and safety of residents in care.
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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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
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