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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004628
Report Date: 11/04/2022
Date Signed: 11/04/2022 10:47:39 AM

Document Has Been Signed on 11/04/2022 10:47 AM - 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:CASA DOCTORA IIIFACILITY NUMBER:
306004628
ADMINISTRATOR:KRAMER, PAUL/ESTELAFACILITY TYPE:
740
ADDRESS:25492 MAXIMUS STREETTELEPHONE:
(949) 380-7379
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
11/04/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Staff on duty-Denmark MangovaTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC 809D on 10/17/2022. LPA De Perio explained reason for visit and was greeted by staff on duty, who contacted facility administrator (AD) Estela Kramer about visit. AD Kramer was unable to be present during time of visit, but provided consent for staff on duty, Denmark Mangova to receive and sign report.

For today's visit, LPA De Perio verified that there are currently 6 residents in care, and 2 staff on duty.

On 10/17/2022, licensee failed to lock disinfectants, cleaning solutions, poisons, and other items which could post a danger. LPA De Perio observed cleaning supplies and disinfectants stored in an unlocked cabinet located under the kitchen sink. This poses an immediate health, safety or personal rights risk to persons in care.

Licensee has secured noted items and now has placed a new lock for disinfectants, cleaning solutions, poisons, and other items. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87309(a) pertaining to Storage Space has been CLEARED.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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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: CASA DOCTORA III
FACILITY NUMBER: 306004628
VISIT DATE: 11/04/2022
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On 10/17/22, facility failed to keep the centrally stored medication in a safe and locked place that is not accessible to residents in care, other than employees responsible for the supervision of centrally stored medication. LPA De Perio observed an unlocked mini refrigerator under the kitchen island that had bottles of liquid medications and pills. LPA De Perio also observed an unlocked medication cabinet located by the staff desk. AD locked refrigerator and cabinet. Threat reduced. This poses an immediate threat on the health and safety of the residents in care.

Licensee has secured and locked noted items and medications are made inaccessible to residents in care. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Incidental Medical and Dental Care has been CLEARED.

For this visit, no deficiencies were issued at this time. No citations issued at this time.

LPA De Perio conducted an exit interview with staff on duty and AD Kramer via phone call and a copy of this report and Letter of Cleared Deficiencies has been provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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