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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006057
Report Date: 10/28/2022
Date Signed: 10/28/2022 04:16:00 PM

Document Has Been Signed on 10/28/2022 04:16 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SOLIVEN CARE HOMEFACILITY NUMBER:
306006057
ADMINISTRATOR:SOLIVEN, JOSELOLITOFACILITY TYPE:
740
ADDRESS:6710 SEQUOIA DR.TELEPHONE:
(714) 310-9293
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Joselolito SolivenTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Administrator (AD) Joselolito Soliven via telephone who later arrived and was present for the visit. AD Soliven is waiting on his new Administrator Certificate to arrive.

At 2:48 PM LPA Haley began the tour of the facility with staff. There were three residents present for the visit. The living room area was clean and well organized. Right next to the front door, there's a locked medication cabinet with two first aid kits, resident, and staff files. In the medication closet hygiene items was observed, along with additional N95 mask. Right next to the medication closet was a screening station with hand sanitizer, temperature thermometer, and several log books.

All resident bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. The resident bathroom was clean and organized. Hot water temperature was measured at 105.1 degrees Fahrenheit.

The kitchen was clean and organized. All knives and sharp objects were locked under the sink. All burners on the stove were operational. There was a knob missing on the stove, but the burner did work. A two day supply of perishable food items and seven day supply of nonperishable food items was observed. A fully charged fire extinguisher was mounted on the wall. A washer and dryer was observed in a rear section of the kitchen. Above the washing machine was a locked cabinet with laundry detergent and additional supply of non-perishable food items.

The garage was clean and well organized. An extra refrigerator with a supply of perishable items was observed. there's a file cabinet with a supply baby wipes. In the garage LPA observed several boxes of adult diapers and a emergency supply of water.


Continued on LIC809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SOLIVEN CARE HOME
FACILITY NUMBER: 306006057
VISIT DATE: 10/28/2022
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The backyard was clean and free of clutter and debris. both side exit gates were self closing and self latching. A shaded patio area, tables and chairs was observed. In the corner of the shaded patio area LPA observed a small storage cabinet with some gardening tools inside. While inspecting the backyard LPA noticed a cracked bedroom window and a door to the facility missing a door knob. AD Soliven was present and acknowledged the broken window and the missing door knob. AD Soliven acknowledged the broken window and said that was his bedroom. LPA Haley advised the importance of keeping the facility in good repair at all times.

No bodies of water was observed. Smoke detectors tested operational.

A deficiency will be cited as a result of todays visit. An exit interview conducted and a copy of the report LIC809D, and Appeal rights were provided to the Administrator Joselilto Soliven.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2022 04:16 PM - It Cannot Be Edited


Created By: Jerome Haley On 10/28/2022 at 03:48 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: SOLIVEN CARE HOME

FACILITY NUMBER: 306006057

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the 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:
During the inspection LPA Haley observed a broken bedroom window, a missing door knob, and a missing knob on the stove. Administrator Soliven was present and acknowledged the presence of the broken window, missing door knob and missing knob on the stove.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses potential safety risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Administrator Soliven will order a new knob for the stove, replace the door knob on the exit door in the kitchen, and have the broken window in his room replaced.
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


LIC809 (FAS) - (06/04)
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