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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005283
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:23:21 PM

Document Has Been Signed on 09/29/2022 04:23 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:ORANGE GROVEFACILITY NUMBER:
306005283
ADMINISTRATOR:GOLDSTEIN, ERICFACILITY TYPE:
740
ADDRESS:22182 ADAMO STREETTELEPHONE:
(949) 279-1700
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 6DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Eric Goldstein, AdministratorTIME COMPLETED:
04:40 PM
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On 09/29/2022 at 3:00pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by caregivers after undergoing the COVID-19 screening procedure and explaining the purpose of the visit. Administrator Eric Goldstein was notified by phone and arrived shortly afterwards to assist with the visit.

At approximately 3:45pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently six (6) residents in care, two (2) of which are receiving hospice care. Residents are observed relaxing in the facility's common areas or in their respective bedrooms. All appear clean and well taken care of. The six individual bedrooms include all necessary components of furnishing. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Physician orders for the residents whose beds are equipped with postural supports are kept in the residents files and presented to LPA when requested.

Sharp instruments are kept in a locked drawer in the kitchen. Cleaning supplies are located in a cabinet under the sink with a magnetic lock as well as in the attached garage. The centrally stored medication is located in a locking metal cabinet in the formal dining area. However lock was non-functional when initially observed. LPA observed a sufficient supply of food and water present. An emergency supply of food is also stored in the attached garage.

LPA observed the facility has COVID-19 Precautions posters and all required department postings along with hand washing signs. The fire extinguishers present are charged and have up-to-date maintenance shown on the attached tags. Sound alarms are present and functional on the facility's exit routes. Staff present is adequately cleared and associated in Guardian.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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: ORANGE GROVE
FACILITY NUMBER: 306005283
VISIT DATE: 09/29/2022
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CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present in the front yard for the enjoyment of residents and visitors. A shed in the backyard is used to store medical equipment, furniture and appliances. The perimeter gate on one side of the house is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, a deficiency are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2022 04:23 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 09/29/2022 at 04:06 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: ORANGE GROVE
FACILITY NUMBER: 306005283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
The California Code of Regulations Section 87465(h)(2) indicates that "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."

This requirement is not met as evidenced by: The metal cabinet used for the storage of medication, first aid equipment and Personal Protection Equipment is demonstrated to have a non-functional locking mechanism during the visit.
Deficient Practice Statement
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Based on observation and interview conducted during the visit, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
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Licensee will ensure that the locking mechanism on the medicine cabinet is repaired and functional before the Plan of Corrections due date indicated above.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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