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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005478
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:16:08 PM

Document Has Been Signed on 11/04/2021 03:16 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: 5DATE:
11/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Soc Yturralde, Caregiver, Roel Atanacio, Caregiver and Rico Almiranez, Licensee/Almiranez via telephoneTIME COMPLETED:
02:44 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted a case management after conducting a Plan of Correction unnanounced inspection visit. On or about 2:09pm along with Caregiver Soc Yturralde toured the inside and outside of the facility. While touring living-room area along with Caregiver Yturralde, LPA Quiroz observed 2 medications for Resident 1 (R1) on top of dining-room table; which was verified with Caregiver Yturralde at 2:09pm. During today's visit, Resident 5 (R5) was observed to be resting on recliner in living-room area. (See attached LIC 809-D and LIC 9102.)

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 Rico Almiranez via telephone and with Caregiver Roel Atanacio. A copy of this report, LIC809-D, Appeal Rights, LIC 9102 were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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 11/04/2021 03:16 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 11/04/2021 at 02:44 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: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2021
Section Cited
CCR
87705(f)(2)

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87705(f)(2):(f)The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol,...cleaning supplies and disinfectants.This requirement was not met as evidenced by: At 2:09pm, LPA Quiroz...CONTINUED BELOW...
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Licensee to ensure all staff working at the facility have received required Medication Training by POC due date and submit proof to CCL by 11/11/2021.
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observed R4's 2 bottles of medications on top of table in living room area while R5 was laying on recliner in livingroom area. 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: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021


LIC809 (FAS) - (06/04)
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