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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006304
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:50:13 AM

Document Has Been Signed on 12/17/2024 11:50 AM - 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:CARE PHOEBEFACILITY NUMBER:
306006304
ADMINISTRATOR/
DIRECTOR:		PAO, ADRIELFACILITY TYPE:
740
ADDRESS:14661 BROOKLINE WAYTELEPHONE:
(714) 368-4627
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:03 AM
MET WITH:Merclo JonathonTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA Samer Haddadin made an announced visit to the facility for purpose of conducting a required annual inspection. LPA arrived at the facility and was greeted and granted entry by staff (S1) Marcelo Jonathon, and later Administrator (AD) Adriel Pao joined the walk-through. The facility is a Residential Care Facility for the Elderly (RCFE) and approved for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients.
LPA started the tour with AD and observed the following:
The facility is a one-story home with five resident bedrooms, two bathrooms, living room, kitchen, dining room, staff room, laundry area, backyard and attached two car garage.

At time of visit, the facility had 6 residents present. Upon inspecting residents’ rooms, LPA observed that rooms were not sanitary or odorless, however, resident rooms were provided with furniture, chair and clean Lenin adequate storage space, and kept free of tripping hazards.


Manual smoke detectors, carbon monoxide and exit alarms were tested to be operational. LPA observed one Dynwoun Cleanser spray in bathroom one. Staff immediately locked it after discovery however, both Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 118.9 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements.
Fire extinguisher was observed with last inspection date of March, 22, 2024 . For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards and ample space for activities.LPA found one pair of scissors and one knife in kitchen sink; staff immediately locked both items. However, Kitchen was in good repair with cleaning supplies and sharp items inaccessible to residents in care.

LPA reviewed residents’ medication and observed that staff does not keep record nor count of medication. However, medications are kept locked separately in hallway.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CARE PHOEBE
FACILITY NUMBER: 306006304
VISIT DATE: 12/17/2024
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 LPA reviewed the rest of resident’s and staff files and all had and contained all required documentation. Upon review of records, the facility does not maintain any records of quarterly fire drill.

Based on the observations made during today’s inspection, 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 and appeal rights were provided to AD at end of inspection.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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Document Has Been Signed on 12/17/2024 11:50 AM - It Cannot Be Edited


Created By: Samer Haddadin On 12/17/2024 at 11:26 AM
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: CARE PHOEBE
FACILITY NUMBER: 306006304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

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
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Based on observation the licensee did not comply with the section cited above for leaving Dynwoun Cleanser in bathroom knife in kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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AD will provide training and E mail LPA proof by POC Due date
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in not recording the right dosage of medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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AD will provide training and E mail LPA proof by POC 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2024 11:50 AM - It Cannot Be Edited


Created By: Samer Haddadin On 12/17/2024 at 11:26 AM
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: CARE PHOEBE
FACILITY NUMBER: 306006304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in not having medication accounted for which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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3
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AD will provide training and E mail LPA proof by POC Due date
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


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