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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 12:12:32 PM

Document Has Been Signed on 11/16/2023 12:12 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Mai Ngyen, Licensee/AdministratorTIME COMPLETED:
12:15 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted a subsequent visit after conducting a Case Management- incident inspection visit to the facility.
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.
On or about 11:04am while inspecting kitchen area, LPA Quiroz observed three bottles of medication containers on kitchen island. Resident 1 (R1) and Resident 2 (R2) were observed to be in close proximity sitting in dining room area. The following three medications were identified to be: Oyster Shell 500-Vitamin D, Olmesartan HCTZ 12.5mg and Fucoiden Pure Extract which were identified to belong to Caregiver 1 (CG1) as evidenced by (CG1)1 saying "Sorry, sorry," and (L/AD) stating "The caregiver was just going to take them." This was verified with (L/AD) Mai Nguyen.
LPA Quiroz provided consultation on California Code of Regulation (CCR) Incidental Medical and Dental Care 87465(a)(h)(2).

Facility cited during today's visit under California Code of Regulation (CCR)87465(a)(h)(2)Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(h)The following requirements shall apply to medications which are centrally stored:(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


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 12:12 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 11/16/2023 at 11:41 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
87465(a)(h)(2)

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(CCR)87465(a)(h)(2)Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(h)The following requirements shall apply to medications which are centrally stored:(2)Centrally stored medicinesCONT...
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(L/AD) Mai Nguyen indicated an inservice training on CCR 87465(a)(h)(2) will be provided to all staff identified on LIC 500 by 11/17/2023 and agreed to provide CCR 87465(a)(h)(2) training to future facility employees.
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CONT... shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by On or about 11:04am while
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CONT... inspecting kitchen area, LPA Quiroz oberved three bottles of medications containers on kitchen island. This was verified with (L/AD) Mai Nguyen. Three medications were verified to belong to CG1. 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


LIC809 (FAS) - (06/04)
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