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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006336
Report Date: 09/30/2024
Date Signed: 09/30/2024 12:11:18 PM

Document Has Been Signed on 09/30/2024 12:11 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:KRISNELLE HOME CAREFACILITY NUMBER:
306006336
ADMINISTRATOR/
DIRECTOR:		JESSICA VILLANUEVAFACILITY TYPE:
740
ADDRESS:9232 MARCHAND AVENUETELEPHONE:
(714) 267-4548
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 5DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jessica VillanuevaTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregiver staff and explained the reason for the visit. Administrator (AD) Jessica Villanueva arrived shortly to assist with the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for six. Currently there are five residents, of which two are on hospice during today's visit.

Around 8:50 AM LPA Tea reviewed five resident files and three staff files. There were discrepancies noted in the review of resident and staff files. Administrator certificate expires on May 1, 2025.



LPA Tea along with the Administrator toured the facility at 9:56 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 3 resident bedrooms, 1 caregiver room, 1 1/2 bathrooms, living room, dining room, kitchen, sunroom and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 117.1 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care locked and secured in cabinets in the garage. The fire extinguisher in the kitchen was fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and two exit gates on the both sides of the facility are self-latching and operational. (continued on LIC809C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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Document Has Been Signed on 09/30/2024 12:11 PM - It Cannot Be Edited


Created By: Michael Tea On 09/30/2024 at 11:33 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: KRISNELLE HOME CARE
FACILITY NUMBER: 306006336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff record, one out of 3 staff files reviewed, one caregiver has first aid and CPR ceritifcation. This could pose a potential health and safety risk to residents in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will provide proof of staff training for CPR/1st Aid by POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's review of resident files, one resident does not have a completed resident appraisal. This can pose as a potential health and safety risk to the resident.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee will provide proof of completed resident appraisal 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:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


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: KRISNELLE HOME CARE
FACILITY NUMBER: 306006336
VISIT DATE: 09/30/2024
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 LPA observed emergency supplies, food and water supply in the kitchen and dining area. Facility provides activities based on resident interests. The residents watch television, do puzzles, reading books and newspapers and walk around the neighborhood. At the time of annual visit, residents were seen reading, doing puzzles and watching television.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the office area. Medications are being administered per physician. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Jessica Villanueva and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102 and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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