<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005478
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:43:02 PM

Document Has Been Signed on 09/26/2023 04:43 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:
09/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Kristine Guevarra, Lead Care GiverTIME COMPLETED:
04:44 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a Case Management- Deficiencies visit in conjunction with Complaint control # 22-AS-20230919143528.

On today's date, on or about 3:40pm as LPA Quiroz was walking towards entrance of facility, LPA Quiroz detected cigarette smell coming from the garage area. LPA Quiroz observed garage door opened, and observed Caregiver 1 (CG1) inside the garage area. While LPA Quiroz was interviewing (CG1), LPA Quiroz observed cigarette smoke throughout the garage area. (CG1) verified cigarette smell/smoke in garage area verifying smoking in garage area. During today's record review, LPA Quiroz verified Resident 1 (R1) who is in close proximity to garage area has oxygen in use.

During today's visit, the following deficiency was observed: California Code of Regulations (CCR): 87618(b)(3)(C) Oxygen Administration - Gas and Liquid:(b)In addition to Section 87611(b), the licensee shall be responsible for the following:(3)Ensuring that the use of oxygen equipment meets the following requirements:
(C)Smoking shall be prohibited where oxygen is in use.

Copy of CCR-87618(b)(3)(C) was provided to (L/AD) via email.

Today's report was reviewed with Lead Caregiver Kristine Guevarra and (L/AD) Almiranez via telephone and a copy of this report, LIC 809-D, LIC 811- Confidential name and Appeal Rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/26/2023 04:43 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 09/26/2023 at 04:26 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: SAINT BENEDICT CARE LLC
FACILITY NUMBER: 306005478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2023
Section Cited
CCR
87618(b)(3)(C)

1
2
3
4
5
6
7
87618(b)(3)(C) Oxygen Administration - Gas and Liquid:(b)In addition to...(3)Ensuring that the use of oxygen equipment meets the...:(C)Smoking shall be prohibited where oxygen is in use. This requirement is not met as evidenced by CONT
1
2
3
4
5
6
7
 L/AD Almiranez will read and understand CCR 87618 and conduct inservice training with all staff and provide proof of understanding and inservice to CCLD by 10/02/2023.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: On today's date, on or about 3:40pm as LPA Quiroz was walking towards entrance of facility, LPA Quiroz detected cigarette smell coming from the garage area. LPA Quiroz observed garage door opened, and observed (CG1) inside the garage area.
8
9
10
11
12
13
14
 (CG1) verified cigarette smell/smoke in garage area verifying smoking in garage area. During today's record review, LPA Quiroz verified Resident 1 (R1) who is in close proximity to garage area has oxygen in use. This poses a potential risk to residents in care.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2