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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006113
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:56:44 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/15/2024 04:56 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:MILES PLACE OF FOUNTAIN VALLEY 2FACILITY NUMBER:
306006113
ADMINISTRATOR/
DIRECTOR:		AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:9367 SISKIN AVENUETELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:33 PM
MET WITH:Jovalyn Galang, Caregiver and Mark Cruz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:02 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting an Annual Required-1 year inspection visit. LPA was greeted by Caregiver 1. Administrator (AD) Mark Cruz arrived shortly after and discussed purpose of the visit. AD Mark Cruz has an Administrator certificate with expiration date of 12/2/2024.

The facility is a two-story house of which second story consists of: 4 bedrooms, and 3 bathrooms which is utilized for caregivers and Administrator headquarters. The first floor consists of: 4 resident bedrooms; of which 2 bedrooms are shared bedrooms and 2 are private bedrooms, 3 bathrooms for staff and residents, living room, dining area, and kitchen. There is a sun-room in the back of the facility next to dining area used as an activity room and for family visitations.

There is an attached 2 car garage with an operational washer and dryer. The backyard has a shaded concrete area for resident and visitor enjoyment. The exit gates on the exterior of the home are locked from the outside have self-closing and self-latching mechanisms in operating condition.

The facility is licensed for age range 60 and over, approved for capacity of 6 (six) Non-Ambulatory residents, and has a hospice waiver for (6) six residents. There are currently (4) four residents currently receiving hospice care services.

LPA along with CG1 toured the interior and exterior of facility. LPA observed kitchen for proper sanitation and cleanliness. LPA observed Sharp objects locked and secured in cabinet in kitchen area, and observed toxin substances to be locked and inaccessible to residents in care in locked and secured closet in garage area. The food was observed to meet the minimum requirement of two days perishable and seven days nonperishable food supply for residents in care.

CONTINUED ON LIC 809-C PAGE...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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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: MILES PLACE OF FOUNTAIN VALLEY 2
FACILITY NUMBER: 306006113
VISIT DATE: 04/15/2024
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CONTINUED...Six of six resident bedrooms were observed to have required furnishings including but not limited to: lamp, bed, mattress, night stand and clean linen. LPA Quiroz interacted and interviewed 3 of 6 residents during facility tour. LPA Quiroz not able to qualify and interview 3 of 6 residents in care. The water temperature in 3 of 3 resident bathrooms were measured to be between 114.7-116.6 degrees Fahrenheit. The Grab bars and non-slip mats were observed in resident bathrooms. Room temperature inside the facility was recorded to be 74 degrees F. During today’s visit, LPA Quiroz observed temperature gage box to be locked and secured. (SEE LIC 9102-TV)
The outside grounds were inspected during facility tour, and no bodies of water were observed. No pool available at this facility. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
LPA observed three fire extinguishers mounted and charged in garage and hallway area, which were last serviced on 3/05/2024. LPA observed and tested functional and operational carbon monoxide and smoke alarms.
(AD) Mark Cruz reports fire drills are conducted quarterly with staff and residents. Last facility fire drill was conducted on March 22,2024.
CG1 reported offering the following indoor and outdoor activities at the facility according to weather conditions: "walks, painting, ball and arm range of motion exercises." LPA Quiroz reviewed whether the facility is operating within capacity limitations and reviewed repeated violations, no repeated violations assessed.
During today's visit, LPAs reviewed six of six resident records and four of four personnel files. Resident and personnel files were found to be within Title 22 California Code of Regulations.
At 3:23pm, LPA Quiroz reviewed centrally stored medications for 6 of 6 residents. During centrally stored medication review, LPA Quiroz observed 4 of 6 resident’s centrally stored Comfort KIT medications consisting of: Acetaminophen, Morphine, Lorazepam, Bisacodyl, Hyoscyamine, Ondansetron and Albuterol in refrigerator in kitchen which is unlocked and unsecured. This poses an immediate risk to residents in care. (SEE LIC 809-D)
During today's visit, LPA Quiroz provided Consultation on Title 22, COVID-19 Mitigation and Infection control throughout today's visit. Based on the observations made during today’s visit; the facility is being cited per Title 22 Division 6 of the California Code of Regulations. This report was read and reviewed with (AD) Mark Cruz, and a copy of this report, LIC 858, LIC 859, LIC 809-D, LI 9102-TV and Appeal Rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2024 04:56 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 04/15/2024 at 04:45 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: MILES PLACE OF FOUNTAIN VALLEY 2
FACILITY NUMBER: 306006113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
CCR
87705(f)(2)

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87705(f)(2):Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).(2) Over-the-counter medication... CONT
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AD Mark Cruz agreed to read and understand CCR 87705 and provide inservice training to all staff identified on LIC 500 by POC Due date of 4/19/2024.
4 of 4 comfort kits were relocated to locked and secured refrigerator in garage area during today's visit.
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This requirement is not met as evidence by: At 3:23pm, LPA Quiroz reviewed centrally stored medications for 6 of 6 residents. During centrally stored medication review, LPA Quiroz observed 4 of 6 resident’s centrally stored Comfort KIT medications consisting of: CONTINUE...
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Acetaminophen, Morphine, Lorazepam, Bisacodyl, Hyoscyamine, Ondansetron and Albuterol in refrigerator in kitchen are which is unlocked and unsecured. This poses an immediate risk to residents in care.

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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024


LIC809 (FAS) - (06/04)
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