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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004510
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:07:50 PM

Document Has Been Signed on 11/16/2023 12:07 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:LOVING CARE SENIOR HOMEFACILITY NUMBER:
306004510
ADMINISTRATOR:MAI T. NGUYENFACILITY TYPE:
740
ADDRESS:9435 KIWI CIRCLETELEPHONE:
(714) 867-8074
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 2DATE:
11/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Mai Nguyen, Licensee/AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit to the facility for the purpose to address a Special Incident Report (SIR) with occurrence date of 10/8/2023 received in Community Care Licensing Orange County Regional Office on 11/9/2023.
LPA Quiroz was greeted and granted entry by Caregiver Tuyet Nguyen. LPA Quiroz called and spoke to Licensee/Administrator Mai Nguyen and discussed purpose of today's visit. (L/AD) Mai Nguyen arrived on or about 10:58am. On or about 11:03am, LPA Quiroz along with (L/AD) Mai Nguyen toured the interior and exterior of the facility premises.
Documentation review of SIR dated 10/8/2023 indicates alleged mistreatment to Resident (1) from Caregiver 1 (CG1) and Caregiver 2 (CG2). L/AD Nguyen indicated "Staff no longer work at the facility. (R1) was relocated to another facility. I don't know where the caregivers are working now."
LPA Quiroz provided consultation of California Code of Regulation (CCR) 87211-Reporting Requirements(a)(1)(D).(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
Facility cited during today's visit under California Code of Regulation (CCR) 87211-Reporting Requirements(a)(1)(D).

An exit interview was conducted with (L/AD) Mai Nguyen, and a copy of this report, LIC 809-D, Appeal Rights and LIC 811-Confidential Names were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 11/16/2023 12:07 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 11/16/2023 at 09:09 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: LOVING CARE SENIOR HOME
FACILITY NUMBER: 306004510

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2023
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D):Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within...CONT BELOW
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(L/AD) Mai Nguyen agreed to read and understand CCR 87211(a)(1)(D)and submit proof of understanding by POC due date of 11/17/2023.
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CONT... seven days of the occurrence of any of the events specified in...(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. CONTINUED...
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CONT...This requirement is not met as evidenced by, On 11/9/2023, Orange County Regional Office received an SIR with occurence date of 10/8/2023 for Resident 1.
This poses an immediate risk to 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


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