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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005505
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:29:09 AM

Document Has Been Signed on 12/20/2024 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SELECT SENIOR CARE LLCFACILITY NUMBER:
306005505
ADMINISTRATOR/
DIRECTOR:		DATCU, DANIELFACILITY TYPE:
740
ADDRESS:1221 N BIG SPRING STTELEPHONE:
(714) 695-9370
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 5DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Brandon MoraTIME VISIT/
INSPECTION COMPLETED:
12:18 PM
NARRATIVE
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Licensing Program Analysts (LPA) Samer Haddadin made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by Staff (S1) Brandon Mora and granted entry into the facility and explained the purpose of the visit. During the inspection LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:
This is a two-story house with seven residents’ bedrooms and three restrooms located on the first level, The second story is for staff and had three staff bedrooms and one restroom. During the inspection LPAs observed two staff on duty and five residents in care.
LPA and S1 tested smoke detectors/carbon monoxide in common areas and bedrooms; all were operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably.
LPAs observed fire extinguisher mounted in kitchen area with last inspection date of on July 18th, 2024. Upon review, fire drill log not conducted nor maintained per regulation . During inspection of the kitchen area, LPAs observed sharps, knives in kitchen drawer to be unlocked, due to a broken lock and accessible to residents in care. LPA observed 2-day supply of perishable and 7-day supply of non-perishable foods and water was observed during today’s visit. Kitchen appliances were observed to be operational during today's visit.
Restrooms toilets and water faucets were also observed to be operational. Grab bars were secure, and showers were observed to be free of mold/mildew. Water temperature measured between at 112.6 degrees Fahrenheit and 113. degrees Fahrenheit. LPAs and S1 toured the backyard of the facility and observed a shaded seating area for residents’ enjoyment. LPAs reviewed three residents’ and three staff files and observed they all had the required documentation.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to staff at end of inspection.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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Document Has Been Signed on 12/20/2024 11:29 AM - It Cannot Be Edited


Created By: Samer Haddadin On 12/20/2024 at 10:49 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: SELECT SENIOR CARE LLC
FACILITY NUMBER: 306005505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
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).

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 having a broken lock on sharps and knivies and were accessible to residents which pose an immediate health, safety risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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AD and or stadd will fix the broken lock and send proof by e mail to LPA by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/20/2024 11:29 AM - It Cannot Be Edited


Created By: Samer Haddadin On 12/20/2024 at 10:49 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: SELECT SENIOR CARE LLC
FACILITY NUMBER: 306005505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onobservation andrecord review, the licensee did not comply with the section cited above in not documenting fire drills which poses a potential health and safety risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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AD and Staff will document the fire drills and maintain it every three months and will E mail LPA proof of POC
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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