306006165-12-13-2022-22-AS-CDPO-CM3SMX-20221213130040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006165
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:01:13 PM

Document Has Been Signed on 12/13/2022 01:01 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:	ABLELIGHT, INC. -- OSPREY		FACILITY NUMBER:	306006165
ADMINISTRATOR:	KUM, JENNIFER		FACILITY TYPE:	740
ADDRESS:	24411 OSPREY STREET		TELEPHONE:	(949) 837-5385
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 4		CENSUS: 4	DATE:	12/13/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Staff on duty-Fely Marcelo		TIME COMPLETED:	01:20 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	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required post-licensing inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Jill Bonnin about visit. AD Bonnin was unable to be present during time of visit, however, provided consent for staff on duty (S1) Fely Marcelo to receive and sign report. NOTE: AD Bonnin's administrator's certificate expires on 3/17/24. As of 12/13/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA De Perio observed administrator's certificate (AD) for Jennifer Kum, which expires on 4/21/24. LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 4 non-ambulatory residents, of which may be 60 years of age and over, with a hospice waive for 2. License also specifies that facility garage is not approved for resident use. For this visit, there are a total of 4 residents in care, of which 1 is on hospice. For today's visit, there is 1 resident in facility care, and 3 residents were attending day program. There are a total of 5 bedrooms, of which 4 are private resident rooms, and 1 is a vacant room, of which is currently under maintenance to be an activity room for residents. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms of which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 108.8 degrees Fahrenheit and hand washing signs were also posted in each restroom.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: ABLELIGHT, INC. -- OSPREY	FACILITY NUMBER: 306006165
	VISIT DATE: 12/13/2022

NARRATIVE

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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Fire extinguisher was charged, mounted and located in the kitchen.

Facility utilizes garage as a staff office. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the staff office. Facility had back-up emergency food and water supply, located in the kitchen and in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in the garage and is made inaccessible to residents in care.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with S1 and AD Bonnin. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Bonnin via phone call to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: ABLELIGHT, INC. -- OSPREY	FACILITY NUMBER: 306006165
	VISIT DATE: 12/13/2022

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LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Bonnin.

For today's visit deficiencies and citations were issued per Title 22 Division 6 of the California Code of Regulations.

LPA De Perio advised AD Bonnin to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with S1 and AD Bonnin and a copy of this report and copies of the regulations discussed were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2022 01:01 PM - It Cannot Be Edited

Created By: Celine DePerio On 12/13/2022 at 12:47 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: ABLELIGHT, INC. -- OSPREY	FACILITY NUMBER: 306006165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309(a) Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms, and other items which could post a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above and did not lock disinfectants, cleaning solutions, poisons, and other items which could post a danger. LPA observed Lysol bleach spray under the bathroom sink and under the kitchen sink. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2022
	Plan of Correction
1 2 3 4	Facility will lock and ensure that all toxins and disinfectants are inaccessible to residents in care and provide training to staff regarding the regulation cited. Facility will comply with the POC on or by 12/27/2022 and submit proof to assigned LPA and Community Care Licensing.

Type A

Section Cited

CCR

86605(f)(1)

87705(f)(1) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, the licensee did not comply with the section cited above and did not lock knives, and other items that could constitute a danger to the resident(s) which could post a danger. LPA observed multiple knives in a plastic box located in an unlocked kitchen cabinet. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2022
	Plan of Correction
1 2 3 4	Facility will lock and ensure all sharps and knives are inaccessible to residents in care and provide training to staff regarding the regulation cited. Facility will comply with the POC on or by 12/27/2022 and submit proof to assigned LPA and Community Care Licensing.

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:

Celine DePerio

LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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