300602548-12-2-2022-22-AS-CDPO-CLQVT7-20221202154240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300602548
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:43:12 PM

Document Has Been Signed on 12/02/2022 03:43 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	KATELLA SENIOR LIVING COMMUNITY		FACILITY NUMBER:	300602548
ADMINISTRATOR:	CHRISTINE GREENWAY		FACILITY TYPE:	740
ADDRESS:	3952 KATELLA AVENUE		TELEPHONE:	(562) 596-2773
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	140	CENSUS: 52	DATE:	12/02/2022
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	02:24 PM
MET WITH:	Director of Nursing-Toni Sims		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to conduct a case management and health and safety check in this facility. LPA De Perio met with Director of Nursing (DON) Toni Sims and stated the purpose of this visit. LPA De Perio toured the interior and exterior portions of the facility with DON Sims. The facility is a two level structure and is licensed for 140 residents of which may be 60 years old and above. Currently, there is a total census of 52 residents in care of which 1 is on hospice in the assisted living portion of the facility. As of 12/2/22, there are 0 active COVID cases in the facility as verified. LPA De Perio observed resident bedrooms to be in good repair, and is equipped with clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 107.8 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on 11/23/22 of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA De Perio also tested pull cords in resident bathrooms of which were observed to be operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA De Perio observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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: 12/02/2022

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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan located on the first floor by the reception area.

For this visit, LPA De Perio did not observe immediate threats on the health and safety of residents in care. No citation has been issued at this time. No deficiency issued.

LPA De Perio conducted an exit interview with DON Sims, and a copy of this report, and information regarding newly assigned LPA was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

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