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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005478
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:57:13 PM

Document Has Been Signed on 10/19/2021 04:57 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:SAINT BENEDICT CARE LLCFACILITY NUMBER:
306005478
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:8925 CANARY AVENUETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
10/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:08 PM
MET WITH:Rico Almiranez, Administrator, Kristine Guevara, CaregiverTIME COMPLETED:
04:58 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted a 10 day visit regarding Complaint Control Number: 22-AS-20211012143927. While conducting 10 day visit, LPA Quiroz along with Caregiver Kristine Guevara toured the inside and outside of the facility. On or about 3: 26pm, while touring kitchen area along with Caregiver Guevara, LPA Quiroz observed lock on refrigerator. LPA Quiroz attempted to open refrigerator and was not able to open refrigerator. Caregiver Guevara indicated "We lock it because Resident 1 (R1) gets up at night and eats everything inside the refrigerator. He forgets he eats, so we lock it." See attached LIC 809-D.

Based on today's inspection visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiency.

This report was reviewed with Administrator Almiranez and a copy of this report, LIC809-D, Appeal Rights were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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 10/19/2021 04:57 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 10/19/2021 at 04:27 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: SAINT BENEDICT CARE LLC
FACILITY NUMBER: 306005478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2021
Section Cited
CCR
87468.1(a)(3)

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87468.1Personal Rights of Residents in All Facilities(3)To be free from punishment, humiliation, intimidation, abuse... interfering with daily living functions such as eating, sleeping, or elimination.This requirement was not met as evidenced by, at 3:26pm LPA Quiroz observed locked refrigerator with lock.
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Licensee to ensure all staff working at the facility have received required Personal Rights Training by POC due date and submit proof to CCL by 10/22/2021.
Lock was removed by Administrator Almiranez during today's visit.
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Caregiver Guevara indicated "We lock it because Resident 1 (R1) gets up at night and eats everything inside the refrigerator. He forgets he eats, so we lock it." This poses a potential risk for 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:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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