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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006381
Report Date: 12/11/2024
Date Signed: 12/11/2024 05:02:52 PM

Document Has Been Signed on 12/11/2024 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:BARR SENIOR COURTYARD IIFACILITY NUMBER:
306006381
ADMINISTRATOR/
DIRECTOR:
PONTOY, MARETIESFACILITY TYPE:
740
ADDRESS:8556 BARR LANETELEPHONE:
(626) 561-8029
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Ban NguyenTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Michael Tea and Fred Arias 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 caregivers Francis Ramirez Jimenez and Astrid Ojeda 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, with a hospice waiver for six. Currently there are four residents, of which one is on hospice during today's visit.

LPAs reviewed four resident files and two staff files. Resident files and staff files contained all required documentation. Administrator Honglan Tran’s administrator certificate expires on July 30, 2026 but is not physically displayed in the facility. LPAs advised LE Nguyen that administrator certificate needs to be displayed in the facility.



LPAs Tea and Arias along with the caregivers toured the facility at 2:39 PM. LPAs toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 4 resident bedrooms, 1 storage room, 2 bathrooms, living room, dining room, kitchen, and detached garage. LPAs 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 152.2 F degrees but warnings signs were posted in the restroom for the hot water. 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. LPAs observed sharps stored in a container and locked in the medication cabinet. LPAs also observed toxin substances to be locked and inaccessible to clients in care secured underneath the kitchen sink.

Annual inspection continued on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 12/11/2024 05:02 PM - It Cannot Be Edited


Created By: Michael Tea On 12/11/2024 at 04:08 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 II

FACILITY NUMBER: 306006381

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation ... (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
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Based on LPA's observation of facility. Resident bedrooms had damages to the walls. Upon walking outside, part of the side gate is in dis-repair and missing parts of the fence This poses as a potential health and safety issue to residents in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee needs to repair wall damages, patch and repaint for residents in care. Licensee needs to repair or remove the gate fencing due to safety measures. Show proof of correction to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


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 II
FACILITY NUMBER: 306006381
VISIT DATE: 12/11/2024
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The fire extinguishers throughout the facility were fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample seating with shade in the backyard. LPAs observed emergency supplies, food and water in the storage room and garage. Facility provides activities based on resident interests. The residents watch television, listen to music, do puzzles, and play Monopoly. They like to go on walks in the morning. A physical therapist comes to the facility do exercise with them. They love to sing and dance. At the time of annual visit, residents were seen watching television and relaxing.

LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet in a staff area. Medications are being administered per physician order, but not properly documented. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiency 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: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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