Care Charlize

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to the facility today to conduct a required annual. LPA was greeted and granted entry by staff and explained the reason for the visit. Facility is licensed for 4 non-ambulatory residents, 2 ambulatory residents which one can be bedridden. Facility has an approved hospice waiver for 4 residents and the home currently has 5 residents. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in bathrooms. The hot water temperature measured between 110.3 and 111.1 degrees Fahrenheit and all smoke detectors were operational. The fire extinguishers are charged and were serviced on March 21st 2025. The facility’s last fire drill was conducted on December 8th 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage in locked hallway closet. LPA observed emergency food and water in facility garage. . LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA confirmed that administrator has a current administrator certificate which expires on June 3rd 2026. Based on observations no deficiencies noted. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 10, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for a deficiency issued on 01/17/2025 during the required annual inspection. LPA was greeted and granted entry by staff and discussed the purpose of the inspection. LPA toured the facility to check the deficiency has been corrected with staff. Five out of six residents were found to have bed rails. Two out of those five residents did not have bed rail orders on file. R1 and R2 have been identified as not having bed rails orders. The Plan of Corrections has not been fulfilled by the assigned POC due date of 01/18/2025, thus not clearing the deficiency. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Sep 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Oct 9, 2025

A written order from a physician indicating a need for the postural support shall be maintained in the resident's record... This requirement is not met as evidenced by: R1 and R2 do not have bed rail orders in the file which posses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: AD stated they will reach out to family for bed rail orders and provide proof to LPA by POC due date.

Type of visit: Office

On today's date, Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analysts (LPAs) Andrea Mendivil and Fred Arias met with Licensee Marian Mejia and Attorney Clinton Hubbard present via telephone on this day for the purpose of discussing ongoing facility issues. The following was discussed: · Concerns regarding recent Annual visit which resulted in 17 citations, 15 Type A and 2 Type B · Licensee's responsibilities of facility oversight · Licensee's requirement to assess residents prior to admission and ensure all preadmission paperwork is completed · Licensee’s responsibility to ensure physical plant is maintained and all construction is reported to CCLD prior to commencing · Licensee’s responsibility to ensure medications are received, provided and maintained as prescribed The Licensee Stated as following during today's meeting: · Licensee will designate a staff as Facility Designated Administrator Back up and provide documentation of LIC 308 by COB on 02/07/2025 - Licensee will provide more oversight at the facility including spending more time at the home and provide updated LIC 500 to reflect Licensee's time at facility and provide documentation by COB 02/07/2025 - Licensee will review and maintain all facility paperwork every 1-2 weeks - CONT on LIC 809- C During the meeting the Department’s Technical Support Program (TSP) was discussed with Licensee. Licensee expressed interest in Technical Support Program (TSP) and has agreed to participate. An exit interview was conducted with Licensee Marian Mejia and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a plan of correction visit. LPA was greeted and granted entry into the facility by Joy Bongsol and explained the reason for the visit. At 8:10AM LPA Mendivil toured the facility, reviewed documents and observed the following: Deficiency cited under Title 22 87506(b)(11) regarding the physician's report for Resident 5 has been cleared LPA Mendivil observed physician's report for R5. Licensee has complied with POC. Deficiency cited under Title 22 87463(b) regarding updated physician's reports for Resident 4 and Resident 6 has been cleared. LPA Mendivil observed updated physician reports and appraisals. Licensee has complied with POC Deficiency cited under Title 22 87456(a)(3) regarding physician's report for Resident 2 (R2) has been cleared. LPA Mendivil observed a physician's report, appraisal and admission agreement. Licensee has complied with POC . Deficiency cited under Title 22 87465(d)(3) regarding usage and notation of PRN has been cleared. Administrator provided MAR for PRNs. Licensee has complied with POC All other citations noted on visit from 01/17/2025 have been cleared by the Administrator prior to POC visit. An exit interview was conducted an a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2025

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) Andrea Mendevil and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 4 non-ambulatory residents, 2 ambulatory residents which one can be bedridden. Facility has an approved hospice waiver for 4 residents and the home currently has 6 residents. Administrator (AD) Adriel Pao arrived shortly to help conduct facility inspection. AD Pao has a valid certificate that expires on July 19,2026. The facility is currently remodeling the kitchen and it is not available for use. LPAs along with staff Joy toured the facility at 8:25 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, living room, dining room, and kitchen as well as 2 restrooms and 1 staff room. 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 between 116.4 degrees F and 117.5 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA observed sharps unlocked in a cabinet in the living room during today's visit. Perishable and non-perishable food supply was checked and not adequately stocked at time of visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility has never conducted quarterly emergency drills. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit did not contain all required items and missing tweezers. Facility conducts activities in the form of exercise and movies. There is no shaded outdoor seating for residents. One out of two exit gates is blocked by construction debris. CONTINUED ON LIC 809C DATED 1/17/2025. LPA observed the emergency food and water supply. There was no emergency water supply during the visit. LPAs reviewed six resident files and three staff files. The staff has not completed the required annual training for 2024 or 2025. Physician's reports were missing for 2 out of 6 residents. There are no reappraisals for 2 out of 2 dementia residents. Bed rail orders were missing for 3 out of 4 residents. The facility temperature measured 66 degrees F during today's visit. LPAs reviewed medication storage and administration. Medications are stored in a locked closet and in the kitchen refrigerator. Based on the observations made during today’s visit, 17 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Jan 17, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection for a change of ownership. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Karmian Calangi. An application to operate a Residental Care Facility for the Elderly (RCFE) for (6) capacity, (2) ambulatory, (3) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 01/09/2023. Structure: The facility is a one-story home with six resident bedrooms, two bathrooms, living room, kitchen, dining room, staff room, backyard and attached two car garage. There are two exit gates in the back yard. The backyard has a shaded seating area. LPA observed no obstacles in backyard. Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Bathrooms:Hot water measured at 110.6 degrees Fahrenheit in one of the common bathrooms and 107 degrees Fahrenheit in the other common bathroom. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored in cabinets above the washer and dryer. Medications, First-Aid Kit & Files: Medication, first aid kit and files will be stored in a locked cabinet in the hallway. Fire Extinguisher: LPA observed the fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. Extinguishers were purchased on 1/17/2024 as evidenced by the Home Depot receipt attached to the extinguishers. Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 8/23/2023. Component III: Information was provided about how to operate the facility within compliance and reporting requirements. Activity Materials: The facility contracts with a third party organizer that plans various outings for the residents. Residents go to parks, the movies, shopping, and more. Residents are also able to socialize with residents from other homes through this program. Linens: A supply of extra linen is stored in the hallway closet. Emergency Phone Numbers, Exit Plan and Menu: Posted and available for review. Food Service: There is 2-day supply of perishable food and a 7-day supply of non-perishable food on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors were tested and observed to be operational. Appliances: Gas stove, oven, refrigerator, dish washer, microwave, washer, and dryer are operational. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated ADthe state’s words, verbatim · CDSS document, Jan 18, 2024