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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005592
Report Date: 06/10/2024
Date Signed: 06/10/2024 01:38:02 PM

Document Has Been Signed on 06/10/2024 01:38 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PRIMACARE HOME AT ROXBURYFACILITY NUMBER:
306005592
ADMINISTRATOR/
DIRECTOR:		LAPID, BEATRIZ SFACILITY TYPE:
740
ADDRESS:4662 ROXBURY DRTELEPHONE:
(949) 683-4661
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 6CENSUS: 4DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:22 AM
MET WITH:Beatriz LapidTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregivers, Arianne Vallestero and Queeny Sabobo and explained the reason for the visit. During today’s visit, LPA met with Beatriz Lapid, the administrator of the facility. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for four. Currently there are four residents, of which one is on hospice during today's visit.

Around 10:52 AM LPA reviewed 2 staff files and training records. LPA reviewed four of four resident records. Residents files and staff files contained all required documentation. Administrator certificate expired on May 23, 2024 however administrator has complied with all course work and is pending renewal at this time.



LPA Tea along with the Administrator toured the facility at 11:29 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 5 resident bedrooms, 2 full bathrooms, living room, dining room, and kitchen. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.2 degrees F to 111.0 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink. Fire extinguisher in the kitchen was fully charged. Kitchen appliances are operational during today's visit.

Annual Report continuation on LIC 809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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 06/10/2024 01:38 PM - It Cannot Be Edited


Created By: Michael Tea On 06/10/2024 at 12:56 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: PRIMACARE HOME AT ROXBURY
FACILITY NUMBER: 306005592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation 87303(a) ... The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations while reviewing records, found insects in the Emergency and Disaster Plan binder which is stored in the kitchen of the facility. This could pose an immediate health risk for residents in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee will sumbit proof of pest control coming to inspect and take care of infestation of insects via email 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:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PRIMACARE HOME AT ROXBURY
FACILITY NUMBER: 306005592
VISIT DATE: 06/10/2024
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 LPA toured the outside grounds and there is ample seating with shade and the two exit gates on both sides of the facilities are self latching and operational. LPA observed emergency food and water supply in the garage. Residents participate in numerous activities such as puzzles, exercises, walking around the facility and the neighborhood. The residents like to lounge in the nice backyard. There is also gardening activities and music therapy as well.

At 11:49 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Beatriz Lapid and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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