300602548-7-14-2021-22-AS-SFRK-C4X89P-20210714221929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300602548
Report Date: 07/14/2021
Date Signed: 07/14/2021 10:21:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	KATELLA SENIOR LIVING COMMUNITY		FACILITY NUMBER:	300602548
ADMINISTRATOR:	CLAIRE CARPENTER		FACILITY TYPE:	740
ADDRESS:	3952 KATELLA AVENUE		TELEPHONE:	(562) 596-2773
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	140	CENSUS: 72	DATE:	07/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Executive Director Lindsay Schroeder		TIME COMPLETED:	03:13 PM

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Licensing Program Analyst (LPA), Shobhana Frank , made an unannounced visit to the facility to conduct a required 1 Year Inspection. LPA Frank was granted entry into the facility by staff Susanne Fiori. LPA Frank reviewed the facility file prior to the visit. LPA Frank toured the facility with Executive Director Lindsay Schroeder A tour of the facility was conducted inside and out of physical plant.
The following was observed

LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, visitors log. LPA observed COVID posters throughout the facility.

This. Facility is Licensed for a capacity of 140 residents, ages sixty (60) and above. The facility is operating in the capacity and conditions approved by CCL There are six resident receiving hospice services. There is no pool or bodies of water accessible to residents in care.

LPA inspected a random selection of resident rooms and bathrooms, tested the call system, and met with residents and staff. Fire extinguishers were fully charged. The facility is equipped with a hard wired smoke detectors and is monitored by the local fire department quarterly. The last fire drill was conducted on 6/4/21. Auditory devices were tested on all exits. The facility appears to be operating within the terms and conditions of their license.

LPA observed 2-day supply of Non-perishable and 7-day supply of perishables food available in the kitchen and refrigerators. Facility refrigerator, frizzier and canned food were inspected. All canned food noted to be within expired date. LPA observed plenty of fresh fruits, vegetable and water available for residents. Meal menus were posted. Kitchen area was free of potential hazards and appeared to be meet sanitary regulations.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KATELLA SENIOR LIVING COMMUNITY	FACILITY NUMBER: 300602548
	VISIT DATE: 07/14/2021

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LPA verified if facility is providing a comfortable temperature due to hot/cold weather condition. Facility temperature measured at 75.8 F. Facility has a working heater to use for the cold weather and air condition/ fans for the hot weather. Activity supplies for the residents were observed in fire side lunge.

Administrator Certificate expires on 9/30/21. Administrator on the premises every day to oversee the business operations and ensure quality care is being provided.

LPA reviewed most recent LIC 808 Mitigation Plan, LIC 500, Personnel Report, , LIC 610 Emergency LIC 308, Designation of Administrator Responsibility and , forms were completed as required.

LPA will return to complete the annual visit at a later date as to not disrupt the residents normal evening routine.

LPA discussed this report with the representative. A copy of this report was provided.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC809 (FAS) - (06/04)

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