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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004198
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:34:25 PM

Document Has Been Signed on 09/09/2024 03:34 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VERSA-CARE HOME IFACILITY NUMBER:
306004198
ADMINISTRATOR/
DIRECTOR:		CHERRY AGUILAFACILITY TYPE:
740
ADDRESS:1576 SPRUCE UNIT ATELEPHONE:
(714) 646-9217
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 3DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Dolores LacwasanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Claudia Gutierrez and William Vanegas made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Dolores Lacwasan. Administrator (AD) Cherry Aguila was contacted by phone and the purpose of the inspection was discussed. AD stated she would be unable to join LPAs for the visit and indicated Staff Lacwasan would be able to assist with the inspection.

During the inspection, LPAs and Staff Lacwasan conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with four resident bedrooms, two bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPAs observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 138.3 degrees Fahrenheit; a Deficiency was cited on today’s date.

LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Carbon monoxide detectors tested operational, and three of six smoke detectors tested operational; a Deficiency was cited on today’s date. Fire extinguisher was observed to be fully charged with service tag dated January 3, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication cabinet was observed to be locked.

LPAs reviewed three of three resident files. Staff files for Staff Lacwasan and AD are not being maintained and were not available for review; a Deficiency was cited on today’s date. (Cont. LIC9099_C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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 11
Document Has Been Signed on 09/09/2024 03:34 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/09/2024 at 02:10 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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above in one of three resident files which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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AD stated a separate, complete, and current record will be maintained for each resident in the facility and proof provided to LPA via email by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 09/09/2024 03:34 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/09/2024 at 02:10 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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

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 in the bathroom floor tile and in three of six smoke detectors, which poses a potential safety risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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AD stated bathroom floor tile and smoke detectors will be repaired and proof provided to LPA via email by POC date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview, and record review, the licensee did not comply with the section cited above in two of two personnel records, which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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AD stated personnel records will be maintained on each employee and proof provided to LPA via email by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 09/09/2024 03:34 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/09/2024 at 02:10 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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview, and record review, the licensee did not comply with the section cited above in two of two staff records, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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AD stated health screening will be obtained for staff and proof provided to LPA via email by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 09/09/2024 03:34 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/09/2024 at 02:10 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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. 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. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two of two staff files which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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AD stated staff training will be completed immediately and proof provided to LPA via email by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 09/09/2024 03:34 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/09/2024 at 02:10 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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two of two staff files, which poses a potential personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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AD stated staff training will be conducted immediately and proof provded to LPA via email by POC date.
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as planned activites are provided, which poses a potential personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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AD stated planned activities will be provided and proof provided to LPA via email by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 09/09/2024 03:34 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/09/2024 at 02:10 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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and staff interview, the licensee did not comply with the section cited above as an emergency and disaster plan was not available for review, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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AD stated an emergency and disaster plan will be completed and maintained and proof provided to LPA via email by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as documentation of drills was not available for review, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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3
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AD stated documentation of drills will be completed and proof provided to LPA via email by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VERSA-CARE HOME I
FACILITY NUMBER: 306004198
VISIT DATE: 09/09/2024
NARRATIVE
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One of three resident files is not being maintained; a Deficiency was cited on today’s date. Staff files did not contain any documentation for initial staff training or staff training conducted; a Deficiency was cited on today’s date. LPAs interviewed residents and staff present. AD arrived at 3:00 p.m.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
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