Community Care Licensing

Document Has Been Signed on 01/17/2025 04:58 PM - It Cannot Be Edited

FACILITY NAME:	CARE CHARLIZE		FACILITY NUMBER:	306006306
ADMINISTRATOR/ DIRECTOR:	CALANGI, KARMIAN		FACILITY TYPE:	740
ADDRESS:	17602 AMAGANSET		TELEPHONE:	(949) 394-8708
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY: 6		CENSUS: 6	DATE:	01/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Adriel Pao		TIME VISIT/ INSPECTION COMPLETED:	05:20 PM

SUPERVISORS NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87303(a)

(a) 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 LPA observation, one out of two exit gates is blocked by constrution debris which poses an immediate safety risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	Debris clearned during today's visit.

Type A

Section Cited

CCR

87309(a)

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, sharps were found in an unlocked cabinet in the living room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	Locks were placed during today's visit.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87555(b)(22)

(b) The following food service requirements shall apply: (22) Adequate space shall be maintained to accommodate equipment, personnel and procedures necessary for proper cleaning and sanitizing of dishes and other utensils. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, kitchen utensils and cookingware are being washed outside with a garden hose onto a table which poses an immediate health risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD agreed to utilize their other license facility close by to sanitize utensils and cookingware.

Type A

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, there is not enough perishable food for a minimum of two days which poses an immediate health risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD will direct staff to shop for food twice a week instead of once a week.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87465(h)(2)

(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 LPA observation medications were store in the refrigerator next to the kitchen without any locks which poses an immediate safety risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	Staff moved medication to refrigerator in locked garage during today's visit.

Type A

Section Cited

CCR

87465(d)(3)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and staff interview, PRN usage for R4 is being provided but not being tracked which poses an immediate health risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	Staff to use MAR for PRN usage by residents.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87506(b)(11)

(b) Each resident's record shall contain at least the following information: (11) The documentation required by Section 87611(a) for residents with an allowable health condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, no physician's report was available to review for R5 which poses an immediate health risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD contacted responsible party. Resident to receive new physician's report on 1/21/2025. AD to send report to LPA.

Type A

Section Cited

CCR

87463(b)

The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of Resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, no reappraisals have been conducted for R4 and R6 diagnosed with dementia since 2020 which poses an immediate health risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD to contact responsible parties and PCPs and receive new reappraisals. AD to send new reappraisals once received to LPA.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87456(a)(3)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, there was not physician's report available for R2 which poses an immediate health risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD contacted doctor to receive Physician's report.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, no pre appraisal has been completed for R2 which poses an immediate health risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD to contact responsible party to review initial admission paperwork and pre appraisal.

Type A

Section Cited

HSC

1569.695(a)(2)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and staff interview, there is no emergency water supply which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD to purchase 15 gallons of emergency water by 1/19/2025. AD to submit receipt of purchase.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

HSC

1569.695(c)

(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 record review, the facility has never completed an emergency drill which poses an immediate safety risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD to complete disaster drill on 1/20/2025 and will submit proof to LPA when completed.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type B

Section Cited

CCR

87219(h)(2)

(h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, there is no shaded outdoor space for residents to rest which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	AD to purchase pop up tent by 1/24/2025. AD to send picture of tent to LPA

Type B

Section Cited

CCR

87465(a)(8)(E)

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (E) Tweezers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, tweezers are missing from the first aid kit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	AD to purchase tweezers by 1/24/2025. AD to send proof to LPA.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
	VISIT DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87608(a)(3)

A written order from a physician indicating a need for the postural support shall be maintained in the resident's record. The licensing facility shall be authorized to require other additional documentation if needed to verify the order This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, R2,R5, and R6 do not have a valid rail order from their physician in their records which poses an immediate safety risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD to contact physicians to receive rail orders. Case worker to be notified. AD to submit proof once rail orders are received.

Type A

Section Cited

CCR

87303(b)(1)

The facility shall heat rooms that residents occupy to a minimum of 68 degrees F, (20 degrees C) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the temperature in the facility measured 66 degrees F based on the information showed in the facility thermostat which poses an immediate health rights risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD set thermostat at 71 degrees during today's visit.

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025

Link to Parent Document Below:

FACILITY NAME: CARE CHARLIZE	FACILITY NUMBER: 306006306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

Type A

Section Cited

CCR

87211(g)

The licensee shall notify the Department, in writing, with thirty (30) days of the hiring of a new administrator This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on AD interview, the AD has been working for the licensee since August of 2024 and the Department was never notified which poses an immediate safety risk to persons in care.
	POC Due Date: 01/18/2025
	Plan of Correction
1 2 3 4	AD to send qualifications to LPA

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Fred Arias LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025