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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006166
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:26:07 PM

Document Has Been Signed on 09/10/2024 04:26 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:INNER CIRCLE ASSISTED LIVING #1, LLCFACILITY NUMBER:
306006166
ADMINISTRATOR/
DIRECTOR:		LIN, ERICFACILITY TYPE:
740
ADDRESS:18332 SERRANO AVETELEPHONE:
(714) 331-7950
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 6CENSUS: 6DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Eric Lin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1. During today’s visit, LPA met with Eric Lin, Administrator (AD).

The facility is a single story building with six private rooms and an approved fire clearance of six non-ambulatory residents of which one may be bedridden. The facility is approved for six residents on hospice. Currently the facility has a census of six residents in care. with three on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 111.5 and 113.7 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on September 10, 2024. The facility’s last fire drill was conducted on August 15, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

LPA reviewed four of four staff training and fingerprint records. One staff member was not associated with the facility and was immediately removed from work. An immediate civil penalty of $500 was assessed. LPA conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has an administrator certificate which is pending renewal which expired on 8/29/2024. Administrator is on the pending renewal list and will expire on August 29, 2026.

(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: INNER CIRCLE ASSISTED LIVING #1, LLC
FACILITY NUMBER: 306006166
VISIT DATE: 09/10/2024
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(Continued from LIC 809)

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Eric Lin, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC421IM and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2024 04:26 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 09/10/2024 at 03:59 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: INNER CIRCLE ASSISTED LIVING #1, LLC
FACILITY NUMBER: 306006166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LIcensing Program Analyst (LPA) observation, interviews, and file record review, the licensee did not comply with the section cited above in one out of four staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Eric Lin, Administrator (AD) immediately removed staff member #1 from the premises and is working to access Guardian to reinstate staff #1 with new Live scan and fingerprints. The Centralized Applications Bureau stated staff #1's original background clearance in staff #1's file was incomplete. AD will email LPA once staff #1 returns to work.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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