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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006290
Report Date:
04/18/2024
Date Signed:
04/18/2024 05:02:50 PM
Document Has Been Signed on
04/18/2024 05:02 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:
MIMI'S SENIOR HOME
FACILITY NUMBER:
306006290
ADMINISTRATOR/
DIRECTOR:
SANSANO, MINERVA
FACILITY TYPE:
740
ADDRESS:
24362 APHENA AVE
TELEPHONE:
(919) 317-0885
CITY:
MISSION VIEJO
STATE:
CA
ZIP CODE:
92691
CAPACITY:
6
CENSUS:
6
DATE:
04/18/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:
Minerva Sansano, Administrator
TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Administrator Minerva Sansano was notified of the visit and arrived later to assist.
During the inspection, LPA and caregiver conducted a tour of the physical plant and observed the following: The facility is a one-story home with six private resident bedrooms, one staff room and two bathrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently six residents in care at the facility, none of which are receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. Medication and sharp items were confirmed to be inaccessible throughout the physical plant. Medication was however observed to be on the dining room table and multiple cabinets with cleaning products were unlocked. The staff room and laundry area were observed to be locked by facility staff. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed six resident files and three staff files.
Based on the observations made during today’s inspection, two type A deficiencies and five type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
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
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Document Has Been Signed on
04/18/2024 05:02 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
04/18/2024
at
04:18 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:
MIMI'S SENIOR HOME
FACILITY NUMBER:
306006290
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose 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 during a tour of the physical plant, the licensee did not comply with the section cited above as multiple cabinets equipped with magnetic locks and contained cleaning supplies including bleach powder were observed to be unlocked throughout the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Facility staff ensured to activate all magnetic locks to ensure the inaccessibility of dangerous items during the visit.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews with facility staff, the licensee did not comply with the section cited above as medication were left on the dining table through the afternoon as they were scheduled to be administered for lunch and dinner instead of being relocated in the central storage. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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2
3
4
The two medications observed were returned to the facility's central medication storage during the visit.
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
04/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
04/18/2024 05:02 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
04/18/2024
at
04:19 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:
MIMI'S SENIOR HOME
FACILITY NUMBER:
306006290
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include 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:
Deficient Practice Statement
1
2
3
4
Based on observation of the physical plant, the licensee did not comply with the section cited above as the sink in one of the bathroom was noted to be covered in white stains and the shower curtain in another bathroom was stained alongside the floor. These pose/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/18/2024
Plan of Correction
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2
3
4
Licensee will ensure the cleanliness of both facility bathrooms and submit evidence to LPA before the plan of corrections due date.
Section Cited
Storage Space
Deficient Practice Statement
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2
3
4
N/A This section does not constitute a citation a was generated because of an error in the CARE tool.
POC Due Date:
Plan of Correction
1
2
3
4
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
04/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
04/18/2024 05:02 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
04/18/2024
at
04:20 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:
MIMI'S SENIOR HOME
FACILITY NUMBER:
306006290
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 records reviewed and an interview with the facility admnistrator, the licensee did not comply with the section cited above as no fire/disaster drills have been formally conducted and documented since March 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/18/2024
Plan of Correction
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2
3
4
Licensee stated they would conduct a fire drill and schedule the next quarterly drills as well as provide proof of correction to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and records reviewed, the licensee did not comply with the section cited above. None of the current six residents are admitted onto hospice, meanwhile multiple beds were observed to be equipped with full rails, including two in the up position, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/18/2024
Plan of Correction
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4
Licensee will remove all full rails from use and obtain physician orders for the use of half-rails if applicable. Proof of the removal and updated orders to be provided to LPA before the plan of corrections due date.
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
04/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
04/18/2024 05:02 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
04/18/2024
at
04:21 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:
MIMI'S SENIOR HOME
FACILITY NUMBER:
306006290
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviewed, the licensee did not comply with the section cited above as one resident diagnosed with dementia had not been reassessed by their physician since 2022. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/18/2024
Plan of Correction
1
2
3
4
Licensee will obtain an updated physician report for the resident in question and forward it to the Department before the plan of corrections due date.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in as the sliding door accessible to the backyard is observed to be equipped with a sound alarm that is not activated. Both side gates exiting from the yard are also not equipped with sound alarm, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/18/2024
Plan of Correction
1
2
3
4
Licensee will ensure that all routes of egress from the facility are equipped with active sound alarms and provide evidence to LPA before the plan of corrections due date.
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
04/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
LIC809
(FAS) - (06/04)
Page:
5
of
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