Phamily Home Elderly Care 2

Type of visit: Required - 1 Year

On October 7, 2025, at 9:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Staff Dung Pham. The facility is licensed to operate for six (6) nonambulatory residents of which two (2) may be bedridden and have a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, two (2) outdoor covered seating areas, and an attached two car garage used as a staff lounge. LPA Kim toured inside and outside of the physical plant with Staff Pham. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 115.7 degrees F and 116.2 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food is stored in the cabinet next to the garage and emergency water and emergency supplies were stored in the garage. The facility has one (1) fire extinguisher that was charged and mounted in the kitchen. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-646-9825) remains available. Evidence of Liability insurance is valid from October 29, 2024, to October 29, 2025. The facility also provided the Evidence of Liability Insurance from October 29, 2025 to October 29, 2026. LPA Kim conducted an audit of five (5) resident files (R1-R5), staff files (S1-S8), and medication and medication administration record. LPA observed R1 is diagnosed with dementia and had their physician’s report dated May 28, 2024, and R2 is diagnosed with dementia and had their last physician’s report dated May 14, 2024. LPA observed R1 had their last appraisal needs and service plan dated July 1, 2024. LPA Kim conducted an interview with one (1) staff. Technical violations were assessed during the visit. R1 had their last appraisal needs and service plan dated July 1, 2024. R1 is diagnosed with dementia and had their physician’s report dated May 28, 2024, and R2 is diagnosed with dementia and had their last physician’s report dated May 14, 2024. An exit interview was conducted, and a copy of this report, LIC811, and LIC9102 were provided to Staff Dung Pham.the state’s words, verbatim · CDSS document, Oct 7, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On October 24, 2024, at 8:45am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by House Manager (HM) Mariafe Omosura. The facility is licensed to operate for six (6) nonambulatory residents of which two (2) may be bedridden and have a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, two (2) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with Staff Russel Cruz. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be were clean. A comfortable temperature of 72 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has one (1) fire extinguisher that was charged, mounted in the kitchen, and inspected on September 23, 2024. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-928-9825) remains available. Evidence of Liability insurance is valid from October 29, 2023 to October 29, 2024. LPA Kim conducted an audit of six (6) resident files (R1-R6), staff files (S1-S6), and medication and medication administration record. LPA Kim conducted two (2) staff interviews. Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to House Manager Mariafe Omosurathe state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Staff abandoned resident at hospital.

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPAs were greeted and granted entry into the facility and met with Caregiver Lolita Orcullo. LPAs explained the reason for the visit. Administrator (AD) Charles Pham arrived shortly after. This agency has investigated the complaint alleging that staff abandoned resident at hospital. Regarding the allegation, the following was revealed: Three of five individuals interviewed confirmed the allegation. During the course of the interviews with witnesses, Witness 1 (W1) reported that Resident 1 (R1) was abandoned at the Hospital. Per W1 R1 is currently at Placentia Linda Hospital and stated that they are having issues finding R1 a home. W1 stated that the AD told the Hospital that he did not want R1 back at the facility. During the course of the interviews with staff, Staff 1 (S1) reported that R1 was not issued an Eviction notice. Per S1 R1 is not coming back to the facility. CONTINUED ON LIC9099-C... Substantiated Per AD he is not able to accept R1 back into the facility due to many complaints about his inappropriate behaviors toward staff. AD reported that R1 did not received an Eviction notice and stated that he told the Hospital to find a new place for R1. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff abandoned resident at hospital is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 22-AS-20240918082726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(3)(4) · Plan of correction due date: Sep 27, 2024

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...(3)Failure of the resident to comply with general policies of the facility. (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463... Based on record review and interviews conducted R1 was not issued a 30-Day Eviction notice. This poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee to issue a 30-Day Eviction notice to R1 and email a copy to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 25, 2024

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on interviews conducted AD reported he is not able to take R1 back into the facility. Per AD he told the Hospital to find a new place for R1. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee to read and sign a statement of understanding. Licensee to email a copy to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin made an unannounced Case Management visit in conjunction with complaint visit 22-AS-20240918082726. LPAs were greeted and granted entry into the facility and initially met with House Manager Mariafe Omosura and explained the reason for the visit. During the course of the complaint investigation, LPA reviewed Resident 1's (R1's) file and observed that a Pre-Admission Appraisal for R1 was not completed. During today's visit LPAs consulted with Licensee on the importance of doing a Pre-Admission Appraisal prior to accepting a new resident. Licensee agreed to email the following documents for R1 by close of business on August 25, 2024: Physican Report, Admission agreement, Needs and Services, progress notes and Pre-Admission Appraisal. Based on today's visit, a deficiency being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with facility representative and a copy was provided as well as Appeal Rights.the state’s words, verbatim · CDSS document, Sep 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87457(a)(c) · Plan of correction due date: Sep 25, 2024

(a)(c)(1)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement was not met as evidence by: Based on records reviewed LPA did not observed a Pre-Admission Appraisal for R1. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee to complete a preadmission Appraisal and email proof to LPA by POC due date.