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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005868
Report Date: 11/07/2024
Date Signed: 11/07/2024 04:31:19 PM

Document Has Been Signed on 11/07/2024 04:31 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:ELEONOR'S PLACE 1FACILITY NUMBER:
306005868
ADMINISTRATOR/
DIRECTOR:		AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:24152 JAGGER STREETTELEPHONE:
(949) 547-5377
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Daryll Avendano, Administrator
Justin Cruz, Manager		TIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the purpose of the visit. Administrator Darryl Avendano and house manager Justin Cruz were notified of the visit via telephone and arrived later to assist.

LPAs accompanied by facility staff conducted a tour of the physical plant and observed the following: the facility is a two-story home with an attached garage accessed from the side of the yard. The upper level is only for use by licensee and staff and is kept inaccessible to residents as verified during the visit. The second level consists of two rooms for use by male and female staff along with an additional bathroom used by staff. The facility has six private bedrooms and three shared bathrooms. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. Bathrooms faucets and toilets are operational. Water temperature was measured at 113.5F and 114F in two bathrooms used for personal hygiene. LPAs observed all beds have linen and blankets. There are half rails used for postural supports in two of the bedrooms and full rails in a third. Physician orders for all three residents reviewed along with hospice plan of care.

There are currently six residents admitted to the facility, four of which are receiving hospice care out of a waiver capacity of six possible hospice residents. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly, however only the most recent drill from September 2024 is observed to be documented. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are fully charged and have been maintained in 2024. CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ELEONOR'S PLACE 1
FACILITY NUMBER: 306005868
VISIT DATE: 11/07/2024
NARRATIVE
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CONTINUED FROM FORM LIC809
There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The routes of egress are free of obstructions.

Most cleaning products are observed to be secure throughout the physical plant, however three bottle of cleaning product and one bottle of bleach are observed to not be secured in the backyard. One type B citation provided on an attached LIC809-D form. The box used to store sharp items also does not lock anymore. Type A citation issued. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders with the exception of one medication for one resident which is not being logged for the month of November 2024. Type B citation issued.

LPAs reviewed six resident files along with two staff files. Resident records include all necessary components. All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training and CPR training verified to be up to date. Health screenings are on file for both staff members.

Based on the observations made during today’s inspection, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and one Technical Violation Advisory Note issued.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2024 04:31 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 11/07/2024 at 04:06 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: ELEONOR'S PLACE 1
FACILITY NUMBER: 306005868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

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 made during the facility visit,, the licensee did not comply with the section cited above as the lockbox used to store sharp items is observed to be broken and no longer locks. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee replaced the lockbox during the visit. Deficiency cleared.
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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/07/2024 04:31 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 11/07/2024 at 04:07 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: ELEONOR'S PLACE 1
FACILITY NUMBER: 306005868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation made during the facility visit, the licensee did not comply with the section cited above as two bottles of cleaning products and a bottle of bleach are observed not to be stored securely in the facility's backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Cleaning products placed in the secure kitchen sink cabinet during the visit. Deficiency cleared.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review during the facility visit, the licensee did not comply with the section cited above as one prescription currently administered to one resident does not appear in the November 2024 Medication Administration Records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee will update the Medication Administration Records and provide documentation of the update to LPA before the plan of corrections due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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