<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005263
Report Date: 03/30/2022
Date Signed: 03/30/2022 10:10:42 AM

Document Has Been Signed on 03/30/2022 10:10 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:FAMILY FIRST HOME CARE INCFACILITY NUMBER:
306005263
ADMINISTRATOR:DERRICK, LISAFACILITY TYPE:
740
ADDRESS:10675 LYNN CIRTELEPHONE:
(562) 261-6218
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6CENSUS: 6DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:43 AM
MET WITH:Lisa Derrick - AdministratorTIME COMPLETED:
10:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Family First Home Care Inc. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Martha Shuma. Caregiver Alma San Diego was also present. Administrator (AD) Lisa Derrick arrived later to assist with the visit. The facility is licensed for 6 non-ambulatory residents. The facility has a Hospice waiver for 3 residents. There are currently 6 residents living in the facility. The last emergency disaster drill was conducted on August 14, 2021. LPA Velazquez observed the Complaint poster was not initially present in the facility and AD Derrick located a copy of it but it was approximately "8 x 10." LPA advised AD to obtain the Complaint poster in the correct size pursuant to regulation. The Ombudsman poster was also not posted in the facility and AD advised to prominently display both the Complaint and Ombudsman posters in the entry way of the facility.


At 8:45 AM LPA Velazquez conducted a tour of the physical plant along with AD Derrick. The 1 story home consists of 5 resident bedrooms with 2 bathrooms. The facility also has a living room, family room, dining area, and kitchen. The 6 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails of varying sizes in the resident bedrooms. AD Derrick was not sure if there were written physician orders for the bed rails present in the resident files. AD Derrick proceeded to remove the bed rails on some of the resident beds. One resident had full bed rails and per AD Derrick that resident is not receiving hospice services. Throughout the tour of the physical plant LPA observed there were no auditory alarms present on most of the exit doors which AD Derrick verified. AD Derrick informed LPA Velazquez that 2 residents have Dementia. AD Derrick proceeded to install auditory alarms throughout the facility and LPA Velazquez found them in operating condition. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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 3
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: FAMILY FIRST HOME CARE INC
FACILITY NUMBER: 306005263
VISIT DATE: 03/30/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 105.8 degrees Fahrenheit in the first bathroom, and at 105.0 degrees Fahrenheit in the second bathroom.

LPA Velazquez inspected the kitchen along with AD Derrick. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. First Aid kit was checked and it was found to be in order. The facility did not have a First Aid manual and LPA Velazquez advised AD Derrick to obtain an updated First Aid manual.

LPA Velazquez along with AD Derrick toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gate was operational. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed AD Derrick to ensure a written physician's order indicating the need for the bed rails is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports which LPA reviewed with AD.




Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Lisa Derrick and a copy of this report along with the appeal rights, and a copy of the LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/30/2022 10:10 AM - It Cannot Be Edited


Created By: Patricia Velazquez On 03/30/2022 at 09:37 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: FAMILY FIRST HOME CARE INC
FACILITY NUMBER: 306005263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
87608(a) Postural Supports. 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 additional documentation to verify the order.

Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care. A resident had full bed rails and per AD Derrick that resident is not receiving hospice services.
POC Due Date: 03/30/2022
Plan of Correction
1
2
3
4
Licensee to ensure there is a written physician order indicating the need for the bed rails in each resident record and submit written proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3