306006163-9-16-2024-22-AS-EKIM-D96RHT-20240916130252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006163
Report Date: 09/16/2024
Date Signed: 09/16/2024 01:05:19 PM

Document Has Been Signed on 09/16/2024 01:05 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:	A+ CARE HOME FULLERTON		FACILITY NUMBER:	306006163
ADMINISTRATOR/ DIRECTOR:	MCKERNAN, JEAN		FACILITY TYPE:	740
ADDRESS:	2401 THORN PLACE		TELEPHONE:	(949) 481-6757
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY: 6		CENSUS: 6	DATE:	09/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Norie Whittaker		TIME VISIT/ INSPECTION COMPLETED:	01:15 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 September 16, 2024, at 8:00am, 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 Caregiver (CG) Jefren Maralit. LPA Kim spoke with Licensee (LI) Norie Whittaker over the phone and explained the purpose of the visit. LI Whittaker arrived at the facility around 11:15am.

The facility is licensed to operate for six (6) nonambulatory residents of which six (6) may be bedridden and have a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) Staff Bedroom, four (4) bathrooms, living area, dining area, kitchen, outdoor patio area, attached one car garage, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with CG Maralit. 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, Resident Room 5, and Staff Room. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 116.6 degrees F to 117.6 degrees F. A comfortable temperature of 70 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 one care garage.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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 3

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: A+ CARE HOME FULLERTON	FACILITY NUMBER: 306006163
	VISIT DATE: 09/16/2024

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 (657-554-0253) remains available. First Aid kit had all the necessary elements. The facility has two (2) fire extinguisher that were charged, mounted in the living area that was serviced on April 29, 2024, and mounted in the resident hallway across from the restroom, which was serviced on May 1, 2024.

LPA Kim conducted an audit of resident files (R1-R6), staff files (S1-S5), and medication and medication administration review. LPA Kim conducted one (1) staff interview and two (2) resident 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 Licensee Norie Whittaker

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/16/2024 01:05 PM - It Cannot Be Edited

Created By: Edward Kim On 09/16/2024 at 12:42 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: A+ CARE HOME FULLERTON	FACILITY NUMBER: 306006163
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA Kim observed S5 was missing LIC501 and LIC503 from their staff files and staff training hours for 2024 for S1-S5 were not available at the time of the visit. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide the LIC501 and LIC 503 for S5 and all the training records for S1-S5 to CCLD via emal to edward.kim@dss.ca.gov by POC due date September 25, 2024.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed and interviewed licensee that the emergency drill log was not available at the time of the visit.This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide a copy of the emergency drill log to CCLD via email to edward.kim@dss.ca.gov by POC due date September 25, 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: 09/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3