<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005889
Report Date: 10/23/2024
Date Signed: 10/23/2024 06:16:15 PM

Document Has Been Signed on 10/23/2024 06:16 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:DEL'S HAVEN IIFACILITY NUMBER:
306005889
ADMINISTRATOR/
DIRECTOR:		MANALO, DIANNAFACILITY TYPE:
740
ADDRESS:29251 VIA SAN SEBASTIANTELEPHONE:
(949) 258-2063
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 4DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Dianna ManaloTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts(LPAs) Joseph Alejandre, Nancy Guillen and Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry. LPAs met with Administrator Dianna Manalo. LPAs and the Administrator toured the facility. Facility is a single story home with 5 bedrooms, 2 bathrooms, family room with a TV, dining room, and a kitchen. Facility has a capacity of 6 non-ambulatory residents of which 1 may be bedridden and a hospice waiver for 4. LPAs observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPAs observed the knives are kept under the sink which is locked. LPAs observed expired shelf stable food in the kitchen cupboard. Staff discarded all the expired food. LPAs observed 2 insects in the kitchen. LPAs observed the refrigerator lining on the inside of the refrigerator is cracked. LPAs observed medications are kept locked in the hall closet. LPAs inspected both bathrooms. Both bathrooms are clean and operational. Hot water measured 106.5 to 106.8 degrees Fahrenheit. LPAs and the Administrator inspected the resident rooms. LPAS observed that in bedroom 1 and bedroom 5 both residents had bed rails. LPAs verified that the residents in bedroom 1 and 5 had orders for bed rails. All bedrooms had the required furniture and linens. LPAs and Administrator toured the garage. The garage is kept locked and used for storage. The garage stores extra food, supplies, and furniture. LPAs and Administrator toured the backyard. The backyard is a deck. No bodies of water observed in the backyard. There is a shaded seating area with a table and chairs for residents to sit outside. The exit gate on the South side of the house is operational. LPAs observed the pathway to the North side of the house had a table, tools, wooden box, and propane tanks. The North side exit gate is operational. Smoke detectors/carbon monoxide detectors tested operational. There is no record of an emergency disaster drill being conducted. LPAs reviewed 6 resident records. No discrepancies observed. LPAs reviewed resident medications. Resident 2 (R2) was missing PRN medication Acetaminophen 325 mg. No other discrepancies observed. LPAs reviewed 2 staff files. Both staff members are background cleared and associated to the facility. Both staff members had the required training. LPAs inspected the First Aid Kit. The first aid kit is missing a complete First Aid Manual, all other elements were present.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 9
Document Has Been Signed on 10/23/2024 06:16 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/23/2024 at 05:07 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: DEL'S HAVEN II
FACILITY NUMBER: 306005889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 residents. The facility did not have Resident 2's (R2) PRN Acetaminophen 325 mg which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
1
2
3
4
Facility staff will order Resident 2's PRN Acetaminophen 325 mg and ensure all residents have all prescribed medication on hand in the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 10/23/2024 06:16 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/23/2024 at 05:38 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: DEL'S HAVEN II
FACILITY NUMBER: 306005889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above, LPAs observed 2 insects in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
1
2
3
4
Licensee agrees to clean the kitchen and have the facility treated by a professional pest control company to eliminate all insects from the facility. Licensee to submit the invoice\bill from the pest control company showing the facility has been treated to the LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/23/2024 06:16 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/23/2024 at 05:38 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: DEL'S HAVEN II
FACILITY NUMBER: 306005889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPAs observed expired shelf stable food in the kitchen cupboard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
1
2
3
4
Licensee agrees to have all expired food thrown away. Licensee agrees to have staff monitor all food for the expiration dates to ensure no expired food is served to residents.
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. There is no record of an emergency drill being conducted at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
1
2
3
4
Licensee agrees to conduct an emergency disaster drill for the facility and to document drill. Licensee to forward proof to the LPA by the POC 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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
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: DEL'S HAVEN II
FACILITY NUMBER: 306005889
VISIT DATE: 10/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A copy of the report along with the Appeal of Rights was provided. An exit interview was conducted with the Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9