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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006025
Report Date: 11/15/2024
Date Signed: 11/15/2024 10:50:26 AM

Document Has Been Signed on 11/15/2024 10:50 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:VIOLET RESIDENTIAL CAREFACILITY NUMBER:
306006025
ADMINISTRATOR/
DIRECTOR:		AMURAO, VIOLETAFACILITY TYPE:
740
ADDRESS:12141 ORA DR.TELEPHONE:
(714) 583-8172
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 6DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:02 AM
MET WITH:Ernesto Lorenzo, Violeta AmuraoTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Ernesto Lorenzo and discussed the purpose of the inspection. Administrator (AD) Violeta Amurao arrived during the inspection.
LPA reviewed Infection Control requirements. At about 8:25AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 6-bedroom, 4-bathroom, one-story house with a detached staff house and an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA and AD observed 3 staff and 6 residents present at the facility. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the one staff bedroom and the detached staff house. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested 118.7 degrees F and 117.5 degrees in the three resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:25AM, LPA reviewed 6 resident files and 4 staff files, interviewed 2 residents and 2 staff, and inspected medications for 6 residents. Facility does not handle resident money.
During the inspection, LPA and AD observed the following: based on observation and admission, Resident #1’s (R1) bed contained a full bed rail but per AD R1 is not on hospice.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 10:50 AM - It Cannot Be Edited


Created By: Sean Haddad On 11/15/2024 at 10:27 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: VIOLET RESIDENTIAL CARE
FACILITY NUMBER: 306006025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and admission, R1's bed contained a full bed rail but per AD R1 is not on hospice, which poses an immediate personal rights risk to persons in care.
POC Due Date: 11/16/2024
Plan of Correction
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Licensee stated they were not aware full bed rails could only be used with residents on hospice but are now aware and will only use full bed rails with hospice residents who have a doctor's order for a full bedrail moving forward. During the inspection, the licensee removed the full bed rail and LPA confirmed. POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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