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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005478
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:43:47 PM

Document Has Been Signed on 04/23/2024 03:43 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/
DIRECTOR:		ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:8925 CANARY AVENUETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:03 AM
MET WITH:Kristine Guevarra, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:57 PM
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On today's date, Licensing Program Analysts (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by House Manager (HM) Kristine Guevarra. LPA Quiroz called Licensee/Administrator (L/AD) Uldarico Almiranez and discussed purpose of today's visit.
This is a Residential Care Facility for the Elderly, licensed to provide services to age range 60 and over, approved for capacity of (6) six Non-Ambulatory residents, of which 1 (one) may be bedridden and has a Hospice waiver approved for 4 hospice residents. There is currently one (1) resident receiving hospice care services. There are no active COVID-19 cases in the facility at this time.
AD Uldarico Almiranez has an Administrator certificate with expiration date of April 10, 2024. AD Almiranez indicated currently in process of renewing Administrator certificate, and agreed to submit copy of renewal to Community Care Licensing upon completion.
LPA along with (HM) Guevarra toured the interior and exterior of the facility. During today's inspection tour, LPA observed 3 of 6 Residents in the living room with staff supervision and 3 of 6 residents in their bedroom resting. LPA Quiroz interacted and interviewed with three caregivers and 3 of 6 residents during today's visit.
LPAs inspected resident's bedrooms and bathrooms. The water temperature in resident's bathrooms were recorded to be within normal limits. LPAs inspected resident's bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPAs observed the emergency and disaster and evacuation plan. Facility has supply of emergency food, water in the garage and kitchen area and PPE in the medication closet readily available for staff and residents in care. Fire extinguisher observed last serviced on March 19, 2024. LPA observed functional and operational washer and dryer in the laundry room area. The disinfectants were observed to be locked and secured.
CONTINUED ON NEXT LIC 809-C PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 306005478
VISIT DATE: 04/23/2024
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On or about 10:25am, while inspecting the kitchen area, LPA Quiroz observed the following in refrigerator area unlocked and unsecured: Ozempic injection, Basaglar injection and Novolog flex pen injection, Simbrinza eye drops and latanprost eye drops readily available for residents in care. On or about 10:36am, while inspecting garage area, LPA Quiroz observed opened door leading to garage area and observed pair of scissors and lighter readily unlocked and unsecured readily available to residents in care. This poses a potential risk to residents in care. (SEE LIC 809-D)
LPA toured the outside of the facility and observed seating and shaded area in the backyard for residents and visitor's enjoyment. LPA reviewed 6 of 6 resident records and centrally stored medications and 4 of 4 personnel files.

Citation issued during today's visit.

During today's visit, LPA provided Consultation on Title 22 and Infection control. An exit interview was conducted with HM Kristine Guevarra, and a copy of this report, LIC 809-D page, Appeal Rights, LIC 858- Client/Resident's records review and LIC 859- Staff Records Review were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2024 03:43 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 04/23/2024 at 11:25 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: SAINT BENEDICT CARE LLC
FACILITY NUMBER: 306005478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited

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87705(f)(1)(2): Care of Persons with Dementia(f)The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).(2)Over-the-counter medication... CONTINUED...
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This requirment is not met as evidenced by:PA Quiroz observed the following in refrigerator area unlocked and unsecured: Ozempic injection, Basaglar injection and Novolog flex pen injection, Simbrinza eye drops and latanprost eye drops readily available for residents in care. CONT...
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On or about 10:36am, while inspecting garage area, LPA Quiroz observed opened door leading to garage area and observed pair of scissors and lighter readily unlocked and unsecured readily available to residents in care. This poses a potential 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:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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