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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005447
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:11:20 PM

Document Has Been Signed on 11/04/2022 04:11 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: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:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Administrator/Licensee Yaninee AsawadiloTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry into the facility by Administrator Yaninee Asawadilo and explained the reason for the visit.

During the visit LPA toured the facility with Administrator. Facility is a 5 bedroom,( 4 resident bedrooms 1 staff bedroom) and 3 bathroom two story home. There are 4 Residents in care. LPA observed proper covid signage upon entrance of facility. Facility has required Department postings. LPA toured all Residents rooms, rooms had required furnishings such as bed, night stand, dresser and chair. All restrooms observed had working wash basin, contained soap, toilet paper, and hand towels. Residents were observed relaxing in the Living room eating lunch and relaxing in bedrooms watching TV. Facility has operating audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are fully charged. Facility has supply of PPE and was advised to get additional PPE. Facility has two refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. LPA observed Administrators certificate expiring 10/23/2023. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Resident files during visit. LPA viewed 4 of 4 clients files. Resident emergency contact information is current. Facility has a designated visitation area.
During Infection Control visit, LPA made the following observations: LPA observed medication bottles left out in unsecured locations in house. LPA also observed sharp scissors inside unlocked hall cabinet. During tour LPA observed a Lysol cleaning toxin spray unsecured in facility restroom. R1 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 and LIC 811 were left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
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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Document Has Been Signed on 11/04/2022 04:11 PM - It Cannot Be Edited


Created By: Jenifer Tirre On 11/04/2022 at 03:26 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: LAMBERT HOME CARE
FACILITY NUMBER: 306005447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
The following should 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 met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in failed to ensure scissors and Lysol cleaning spray were inaccesibile to residents with Dementia. R1 has a diagnosis of Dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2022
Plan of Correction
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Licensee secured items during visit. Licensee to conduct staff training on securing harmful items. Licensee to provide Employee statement of understanding by COB 11/7/22
Type A
Section Cited
CCR
87465(h)(2)
Incidental medical and dental services. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervison of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in Licensee failed to ensure medications are inaccessible to persons other than employees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2022
Plan of Correction
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Licensee to ensure residents medications to be centrally stored and not accessible to persons other than employees. Administrator agrees to keep medications in secure location. Administrator to conduct staff training and have employees sign statement of understanding and submit to department by COB by 11/07/22
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:Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
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