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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005983
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:59:56 PM

Document Has Been Signed on 06/13/2024 04:59 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:LA PALMA HOMECAREFACILITY NUMBER:
306005983
ADMINISTRATOR/
DIRECTOR:		BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:1418 W LA PALMA AVETELEPHONE:
(714) 833-5911
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Jimmy Infante and Janet InfanteTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On June 13, 2024 at 1:40pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Caregivers Jimmy Infante and Janet Infante, and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory and have a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living room, dining room, kitchen, an attached garage, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant Caregiver Infante. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident 4, Resident Room 5, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 106.7 degrees F to 109.1 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency supplies, food, and water are in order and complete. The facility has one (1) fire extinguisher that is charged and that was serviced on March 5, 2024, smoke detectors, and carbon monoxide detectors were operable. The facility conducted Fire/Safety Drill March 14, 2024 and is done quarterly. A working telephone (714-833-5911) remains available.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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: LA PALMA HOMECARE
FACILITY NUMBER: 306005983
VISIT DATE: 06/13/2024
NARRATIVE
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. First Aid Kit contained all the necessary elements.

LPA Kim conducted an audit of resident files (R1-R5), staff files (S1-S7), and medication and medication administration review. LPA Kim conducted two (2) staff interviews and five (5) resident interviews.

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of this report was provided to Caregivers Jimmy Infante and Janet Infante.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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Document Has Been Signed on 06/13/2024 04:59 PM - It Cannot Be Edited


Created By: Edward Kim On 06/13/2024 at 04:50 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: LA PALMA HOMECARE
FACILITY NUMBER: 306005983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia(c)Licensees who accept and retain residents with dementia shall be
responsible for ensuring the following:(5)Each resident with dementia shall have an annual medical assessment as
specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include
a reassessment of the resident’s dementia care needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed R2 had a physician's report from March 12, 2023 and an Appraisal Needs and Service Plan from March 13, 2023 with the resident diagnosed with dementia. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee states they will send an updated Physician's Report and Appraisal Needs and Service Plan to CCLD via email to edward.kim@dss.ca.gov by June 21, 2024
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


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