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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003858
Report Date: 06/06/2024
Date Signed: 06/06/2024 12:34:43 PM

Document Has Been Signed on 06/06/2024 12:34 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:ST. FRANCIS' HOME CAREFACILITY NUMBER:
306003858
ADMINISTRATOR/
DIRECTOR:
RAYMOND MENDOZAFACILITY TYPE:
740
ADDRESS:23822 VIA NAVARRATELEPHONE:
(949) 916-9957
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:Raymond MendozaTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Tea and Jessica Cho conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs Tea and Cho were greeted and granted entry into the facility by administrator, Raymond Mendoza and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for four. Currently there are five residents, of which two are on hospice during today's visit.

LPAs Tea and Cho along with the Administrator toured the facility at 9:10 AM. LPAs toured the physical plant, checked food service, and the first aid kit. The home consists of 6 resident bedrooms, 1 staff bedroom, 5 full bathrooms, living room, dining room, and kitchen. LPAs observed smoke detectors/carbon monoxide in common areas and bedrooms and operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105 degrees F to 105.9 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed sharps locked in a kitchen drawer. LPAs also observed toxin substances to be locked and inaccessible to clients in care locked and secured underneath the kitchen sink. The fire extinguisher in the kitchen was fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample seating with shade and the two exit gates on both sides of the facilities are self latching and operational. LPAs observed emergency food in the kitchen and water supply in the garage. Facility provides activities based on resident interests, in the form of outdoor activities such as going out for walks and doing exercises.



Continuation of annual inspection on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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 06/06/2024 12:34 PM - It Cannot Be Edited


Created By: Michael Tea On 06/06/2024 at 11:22 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: ST. FRANCIS' HOME CARE

FACILITY NUMBER: 306003858

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs review of resident records, 3 out of 5 does not have doctor's order for bedrails. This could be an immediate health and safety risk for residents in care.
POC Due Date: 06/07/2024
Plan of Correction
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Licensee will either remove or obtain doctor's order for bedrails for three residents and to submit proof of correction to LPA Tea and Cho via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2024 12:34 PM - It Cannot Be Edited


Created By: Michael Tea On 06/06/2024 at 11:22 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: ST. FRANCIS' HOME CARE

FACILITY NUMBER: 306003858

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs review of two staff records, 2 out of 2 staff CPR and 1st Aid certification were expired. This poses a potential health and safety risk for residents in care.
POC Due Date: 06/21/2024
Plan of Correction
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Adminstrator will provide proof of certifications for two out two staff to LPAs via email by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs review of staff records there is no documentation of annual staff training, which poses a potential health and safety risk to residents in care.
POC Due Date: 07/08/2024
Plan of Correction
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Adminstrator will provide proof of training for staff to LPAs via email by 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2024 09:44 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/10/2024 08:11 AM


Created By: Michael Tea On 06/06/2024 at 11:22 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST. FRANCIS' HOME CARE

FACILITY NUMBER: 306003858

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs review of resident records, 3 out of 5 residents records does not have current physical exam reports, which poses as a potential health and safety risk to residents in care.

**This is an amended report**
POC Due Date: 07/12/2024
Plan of Correction
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Licensee will email copies of current Physician report to submit for proof of correction to LPA Tea on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


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: ST. FRANCIS' HOME CARE
FACILITY NUMBER: 306003858
VISIT DATE: 06/06/2024
NARRATIVE
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The residents watch television, listen to music, reading books and newspapers and completing puzzles.

At 9:46 AM LPAs Tea and Cho reviewed five resident files and one staff file. There were discrepancies noted in the review of resident and staff files. Administrator certificate expired on Jan 14, 2024 however administrator has complied with all course work and is pending renewal at this time.

At 10:18 AM LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Raymond Mendoza and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102 and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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