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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006034
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:55:05 PM

Document Has Been Signed on 10/24/2024 02:55 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:PHAMILY HOME ELDERLY CARE 2FACILITY NUMBER:
306006034
ADMINISTRATOR/
DIRECTOR:
PHAM, CHARLESFACILITY TYPE:
740
ADDRESS:16652 HUGGINS AVETELEPHONE:
(657) 724-9930
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:House Manager Mariafe OmosuraTIME VISIT/
INSPECTION COMPLETED:
03:10 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
On October 24, 2024, at 8:45am, 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 was greeted and granted entry by House Manager (HM) Mariafe Omosura.

The facility is licensed to operate for six (6) nonambulatory residents of which two (2) may be bedridden and have a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, two (2) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with Staff Russel Cruz. There were 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. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be were clean. A comfortable temperature of 72 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 food, emergency water, and emergency supplies were stored in the garage. The facility has one (1) fire extinguisher that was charged, mounted in the kitchen, and inspected on September 23, 2024.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 5
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: PHAMILY HOME ELDERLY CARE 2
FACILITY NUMBER: 306006034
VISIT DATE: 10/24/2024
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
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. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-928-9825) remains available. Evidence of Liability insurance is valid from October 29, 2023 to October 29, 2024.

LPA Kim conducted an audit of six (6) resident files (R1-R6), staff files (S1-S6), and medication and medication administration record. LPA Kim conducted two (2) staff interviews.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to House Manager Mariafe Omosura

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

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/24/2024 02:55 PM - It Cannot Be Edited


Created By: Edward Kim On 10/24/2024 at 02:17 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: PHAMILY HOME ELDERLY CARE 2

FACILITY NUMBER: 306006034

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed bathroom #1 measure at 143.7 degrees Fahrenheit and bathroom #2 measure at 144.1 degrees Fahrenheit. The licensee did not comply with the section cited above in two out of two bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
1
2
3
4
Licensee adjusted the temperature to bathroom #1 to measure at 106.1 degrees Fahrenheit and bathroom #2 meaure at 108.3 degrees Fahrenheit. Licensee states they will send a water temperature log for every 2 hours measuring the water temperature of each sink from October 24, 2024, 5:00pm to October 25, 2024, 5:00pm.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/24/2024 02:55 PM - It Cannot Be Edited


Created By: Edward Kim On 10/24/2024 at 02:17 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: PHAMILY HOME ELDERLY CARE 2

FACILITY NUMBER: 306006034

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, LPA observed the front left burner on the oven was not lighting up. The licensee did not comply with the section cited above in one out of six burners which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee states they will send POC correction to CCLD via email to edward.kim@dss.ca.gov by POC due date November 7, 2024.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, LPA observed S1, S2, S3, S4, S5, and S6 training hours of 2024 were not available from the facility at the time of the visit. The licensee did not comply with the section cited above in six out of six staff members which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee states they will send the missing 2024 training hours for S1, S2, S3, S4, S5, and S6 to CCLD via email to edward.kim@dss.ca.gov by POC due date November 7, 2024.
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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/24/2024 02:55 PM - It Cannot Be Edited


Created By: Edward Kim On 10/24/2024 at 02:17 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: PHAMILY HOME ELDERLY CARE 2

FACILITY NUMBER: 306006034

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
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
1
2
3
4
Based on observation, interview, and record review, LPA observed R2 and R3 did not have a current medical assessment. R2, R3, R4, and R5 did not have a current reappraisal and needs service plan The licensee did not comply with the section cited above. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee states they will send the an updated Phsyicians report for R2 and R3, and reappraisal for R2, R3, R4, and R5 to CCLD via email to edward.kim@dss.ca.gov by POC due date November 7, 2024.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5