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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005845
Report Date: 12/15/2022
Date Signed: 12/15/2022 10:49:41 AM

Document Has Been Signed on 12/15/2022 10:49 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SANTA MARIANA CAREFACILITY NUMBER:
306005845
ADMINISTRATOR:LIMPIADO, GIDEONFACILITY TYPE:
740
ADDRESS:18676 SANTA MARIANATELEPHONE:
(949) 349-8708
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
12/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Karmian Galang, Administrator and Roel Atanacio, CaregiverTIME COMPLETED:
10:50 AM
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On today's date, LPA Quiroz conducted a Case Management- Deficiencies subsequent visit after conducting 10 day investigation visit for complaint control #22-AS-20221208111421. LPA Quiroz met with Administrator Assistant Karmian Galang via telephone and with Caregiver 2 (CG2). During today's visit, LPA Quiroz conducted review of resident files for 6 of 6 residents but not limited to: physician reports, identification forms and needs and services plan.

During today's review of documents, LPA Quiroz observed R1 has no physician report on file. This was verified with Administrator Assistant Karmian Galang via telephone who indicated "Having trouble getting it from VA Hospital."

Based on today's observation and documentation reviewed, facility is being cited for violation of Title 22, Division 6, of California Code of Regulation 87458(a) Medical Assessment (a): Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.


Today's report was reviewed with Facility staff and with Administrator Assistant Karmian Galang via telephone, and a copy of this report, LIC 809-D, LIC 811- Confidential name, Appeal Rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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 12/15/2022 10:49 AM - It Cannot Be Edited


Created By: Rosie Quiroz On 12/15/2022 at 10:32 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: SANTA MARIANA CARE
FACILITY NUMBER: 306005845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2022
Section Cited
CCR
87458(a)

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87458 Medical Assessment(a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year...This requirement was not met as evidenced by: R1 does not have a physian report CONTINUED
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Administator Galang will read and understant CCR 87458, submit proof of understanding CCR 87458 and submit Resident 1's physician report to CCL by POC due date of 12/22/2022.
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on filed. This was verified with Administrator Assistant Karmian Galang who indicated "Have been having trouble getting it from VA Hospital." This poses a potential risk for 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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022


LIC809 (FAS) - (06/04)
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