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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005447
Report Date: 08/01/2022
Date Signed: 08/01/2022 10:43:19 AM

Document Has Been Signed on 08/01/2022 10:43 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:LAMBERT HOME CAREFACILITY NUMBER:
306005447
ADMINISTRATOR:ASAWADILO, YANINEEFACILITY TYPE:
740
ADDRESS:8191 LAMBERT DRIVETELEPHONE:
(714) 848-1982
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 4DATE:
08/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Yaninee AsawadilokchaiTIME COMPLETED:
09:00 AM
NARRATIVE
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On this day Licensing Program Analysts (LPAs) Jenifer Tirre and Kimberly Lyman made an unannounced case management visit in conjunction with complaint visit 22-AS-20220711084817. LPAs were granted entry by staff. LPAs identified themselves and discussed purpose of the visit with Caregiver Sataporn Kitnukul. Administrator Yaninee Asawadilokchai arrived during the visit.

Upon entry into the facility, LPAs observed Staff 1 (S1) with a syringe in hand in the kitchen. S2 and S3 confirmed S1 was a new staff at the facility. S1 immediately exited the facility before LPAs could speak with the staff. LPAs inquired where S1 went and LPAs were told the staff went across the street. Present staff referred LPAs to Administrator for more information regarding status of staff. Administrator arrived during the visit and stated S1 is a friend of current staff. LPAs inquired about S1 administering medications with a syringe and Administrator denied the allegation. LPA Lyman confirmed through Regional Office that S1 does not have criminal record clearance. During medication review related to the complaint visit, LPAs observed Resident 1 (R1) and R2 have seven days of pre-poured medications in unlabeled containers. LPAs observed unsecured knives and scissors in an unsecured kitchen cabinet, a knife in a dishwasher rack and Windex unsecured under the kitchen cabinet. R3 has a diagnosis of Dementia.




Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations Title 22.

An exit interview was conducted and a copy of this report along with appeal rights were left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
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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Document Has Been Signed on 08/01/2022 10:43 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 08/01/2022 at 09:02 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: LAMBERT HOME CARE
FACILITY NUMBER: 306005447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2022
Section Cited
CCR
87355(e)(1)

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All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department..This requirement is not being met as evidenced by:
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Licensee to obtain criminal record clearance for S1 and forward proof to LPA by POC due date.
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Based on observation and interview, Licensee failed to ensure S1 has criminal record clearance before working in the facility. LPAs observed S1 in the facility with a syringe in hand. S1 exited the facility before LPAs could speak with S1. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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Type A
08/02/2022
Section Cited
CCR87355(e)(1)

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Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not being met as evidenced by:
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Licensee to discontinue pre-pouring medications and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure medications are kept in the original container. During medication review, LPAs observed R1 and R2's medications are pre-poured for seven days. This poses an immediate health and safety 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:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/01/2022 10:43 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 08/01/2022 at 10:01 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: LAMBERT HOME CARE
FACILITY NUMBER: 306005447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2022
Section Cited
CCR
87705(f)(1)

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The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not being met as evidenced by:
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Licensee secured items during the visit. CLEARED DURING VISIT.
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Based on observation, Licensee failed to ensure Knives, scissors and Windex were inaccesible to residents with Dementia. R3 has a diagnosis of Dementia.This poses an immediate health and safety 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:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
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