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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005780
Report Date: 01/14/2025
Date Signed: 01/14/2025 05:26:51 PM

Document Has Been Signed on 01/14/2025 05:26 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:CANDLEBERRY CAREFACILITY NUMBER:
306005780
ADMINISTRATOR/
DIRECTOR:		ROSARIO, ROBERTO DELFACILITY TYPE:
740
ADDRESS:4216 CANDLEBERRY AVE.TELEPHONE:
(949) 290-6006
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY: 6CENSUS: 5DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Shellad YturraldeTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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On this day Licensing Program Analysts (LPAs) William Vanegas and Fred Arias and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 2 residents on hospice. Administrator (AD) Ulderico Almiranez arrived shortly to help with the visit. AD Almiranez has a valid certificate that expires on April 10, 2026.

LPA along with Lead Staff Shellad Yturralde toured the facility at 9:00 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 4 resident bedrooms, living room, dining room, and kitchen as well as 2 restrooms and 1 staff room. 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 113.7 degrees F and 114 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the emergency disaster plans and plans are complete and thorough. Facility conducts emergency drills with the last drill conducted on 8/9/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise and outings. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPA observed the emergency food and water supply.
CONTINUED ON LIC 809C DATED 1/14/2025.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 6
Document Has Been Signed on 01/14/2025 05:26 PM - It Cannot Be Edited


Created By: Fred Arias On 01/14/2025 at 04:13 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: CANDLEBERRY CARE
FACILITY NUMBER: 306005780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, medications were found to be stored outside the locked medical cabinet accessible to residents. Medications were observed stored in kitchen upper cabinets above designated medication cabinets. Cabinet does not have a lock. This poses an immediate safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Facility placed all medication into the locked medication cabinet during the visit.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, medications for Resident 5 (R5) were removed from the original container and placed into a separate pre-poured pill box container. LPA unable to verify R5's medications were being given as prescribed. This poses an immediate safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Facility to contact pharmacy to request repacking into new combined bubble packs. Facility to audit medications. Facility to contact LPA on resolution.
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:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/14/2025 05:26 PM - It Cannot Be Edited


Created By: Fred Arias On 01/14/2025 at 04:13 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: CANDLEBERRY CARE
FACILITY NUMBER: 306005780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and staff interview, Resident 1 (R1) medication is not being administered according to the physician's instructions. R1 was prescribed a stool softner to be given routinely. However, per staff, R1's hospice verbally instructed staff to administer as needed. Facility did not obtain a new written order. LPA unable to confirm order changes. This poses an immediate health risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Adminstrator will be notified and will have hospice write new order.
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:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/14/2025 05:26 PM - It Cannot Be Edited


Created By: Fred Arias On 01/14/2025 at 04:13 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: CANDLEBERRY CARE
FACILITY NUMBER: 306005780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

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 on record's review, the facility did not concuct an emergency drill in the fourth quarter of 2024. Last drill was conducted on August 09, 2024. This poses a potential safety risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
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Facility will conduct emergency drills by January 19th, 2025
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:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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: CANDLEBERRY CARE
FACILITY NUMBER: 306005780
VISIT DATE: 01/14/2025
NARRATIVE
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 LPAs reviewed five resident files and three staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. LPA observed some medications stored outside the designated medication locked cabinet. LPA reviewed medication for 3 of 5 residents. Medications for 1 resident were stored outside the original container. One medication for 1 resident was not being administered per physician's order.

Based on the observations made during today’s visit, 4 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy of this report and appeal rights was provided at the time of exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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