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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006373
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:52:31 PM

Document Has Been Signed on 12/09/2024 04:52 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:BARR SENIOR COURTYARD IFACILITY NUMBER:
306006373
ADMINISTRATOR/
DIRECTOR:		PONTOY,MARETIESFACILITY TYPE:
740
ADDRESS:8552 BARR LANETELEPHONE:
(626) 561-8029
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:00 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 Isabel Vargas and explained the reason for the visit. Licensee (LE) Ban Nguyen arrived shortly to assist with the visit. Facility is licensed for six non-ambulatory residents, of which one may be bedridden and with a hospice waiver for six. Currently there are five residents, of which two are on hospice during today's visit.

LPA Tea reviewed five resident files and two staff files. There were discrepancies noted in the review of resident and staff files. Administrator Honglan Tran’s administrator certificate expires on July 30, 2026.



LPA Tea along with the Administrator toured the facility at 2:19 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 5 resident bedrooms, 1 caregiver room, 3 bathrooms, spare/storage room, living room, dining room, kitchen, office area and 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 109 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 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 secured underneath the kitchen sink. The fire extinguishers throughout the facility were fully charged. Kitchen appliances are operational during today's visit.

Annual inspection continued on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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 12/09/2024 04:52 PM - It Cannot Be Edited


Created By: Michael Tea On 12/09/2024 at 04:09 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: BARR SENIOR COURTYARD I
FACILITY NUMBER: 306006373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 records, pre-placement and needs and services forms are not filled out and are incomplete. This could pose as a potential health and safety risk to residents in care.
POC Due Date: 12/23/2024
Plan of Correction
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Licensee will provide proof of completed pre-placement and needs and services forms to LPA by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Person with Dementia ... 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
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Based on LPA's review of resident's records with dementia, there are no current medical reports, they are outdated. This could be a potential health and safety risk to residents in care.
POC Due Date: 12/23/2024
Plan of Correction
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Licensee will provide updated medical reports to LPA 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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


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: BARR SENIOR COURTYARD I
FACILITY NUMBER: 306006373
VISIT DATE: 12/09/2024
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 LPA toured the outside grounds and there is ample seating with shade in front of the house. LPA observed emergency supplies and water in the garage. Licensee had ordered emergency food already and will arrive shortly to the facility. Facility provides activities based on resident interests. The residents watch television, listen to music, play bingo, color, arts and go for walks outside. There is also music therapy, and they love to dance. At the time of annual visit, residents were seen watching television, walking around the front yard and doing word search puzzles.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in a staff area. Medications are being administered per physician order. 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 Licensee Ban Nguyen 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: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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