300602548-8-16-2024-22-AS-BALN-D87PWP-20240816114103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300602548
Report Date: 08/16/2024
Date Signed: 08/16/2024 11:41:12 AM

Document Has Been Signed on 08/16/2024 11:41 AM - 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:	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: 51	DATE:	08/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jon Peralez- Executive Director		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Jon Peralez- Administrator who assisted with the tour of the facility.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, ombudsman poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care.

LPA observed there was a designated storage space for resident/staff files. Medications are kept locked in storage cabinet and medication office inaccessible to residents in care. Medications were audited at random and appeared to be dispensed appropriately by staff members. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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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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: KATELLA SENIOR LIVING COMMUNITY	FACILITY NUMBER: 300602548
	VISIT DATE: 08/16/2024

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Record Review: LPA also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Jon Peralez- Administrator at the conclusion of the visit. Medications were audited at random and appeared to be dispensed appropriately by staff members.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC809 (FAS) - (06/04)

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