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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006047
Report Date: 11/01/2024
Date Signed: 11/01/2024 03:28:59 PM

Document Has Been Signed on 11/01/2024 03:28 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:KNOTT'S LANDING LUXURY CAREFACILITY NUMBER:
306006047
ADMINISTRATOR/
DIRECTOR:		RAJPOOT, FAISALFACILITY TYPE:
740
ADDRESS:6359 ARNOLD WAYTELEPHONE:
(714) 735-8972
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
11/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Vicotria Paul Via TelephoneTIME VISIT/
INSPECTION COMPLETED:
03:40 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
This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Jerome Haley. LPA was greeted and granted entry and explained the reason for the visit upon entry. Staff contacted Administrator (AD) Victoria Paul who arrived a few minutes later and was present the remainder of the visit. Before AD Paul arrived LPA Haley toured the interior of the facility with staff.

Upon further investigation of the incident report dated October 30, 2024 for an incident that occurred on the same date (10.30.24) revealed the following information:



Due to a lack of supervision, Resident 1 (R1) was able to successfully leave the facility without staff and make it to a neighboring property. R1's whereabouts were unknown for about an hour. Document review revealed R1 has a dementia diagnosis and is unable to leave the facility unassisted.

According to S1, R1 was showered and placed back in the bed around 7:00am. Around 7:30am staff realized R1 was missing. An additional facility staff arrived a few minutes later and watched the other residents, while the other staff person went to locate the resident. At 8:08am, R1 was found at a neighbor’s house.

As a result of today’s Case Management visit, a deficiency will be cited.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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 2
Document Has Been Signed on 11/01/2024 03:28 PM - It Cannot Be Edited


Created By: Jerome Haley On 11/01/2024 at 01:19 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: KNOTT'S LANDING LUXURY CARE
FACILITY NUMBER: 306006047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2024
Section Cited
CCR
87464(f)(1)

1
2
3
4
5
6
7
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator Victoria Paul will schedule an in-service training for all staff.
After the training is completed, Administrator Paul will email LPA Haley the sign-in sheet for all staff in attendance, a detailed breakdown of the topics covered during the training, and the duration of the training.
The in-service training needs to be scheduled for all staff and details need to be emailed to LPA Haley by 12:00 noon on the POC due date.
8
9
10
11
12
13
14
On October 30, 2024 around 7:00am Resident 1 was able to leave the facility unassisted and whereabouts were undetermined for about an hour. This poses a health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2