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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606398
Report Date: 07/22/2021
Date Signed: 07/22/2021 11:43:22 AM

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:YORK RETIREMENT HOMES, INC.FACILITY NUMBER:
300606398
ADMINISTRATOR:JACOBSEN, DONALDFACILITY TYPE:
740
ADDRESS:22391 LOMBARDITELEPHONE:
(949) 770-1348
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 5DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Erlinda Monette GallardoTIME COMPLETED:
11:48 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by caregiver and granted entry. LPA met with caregiver and explained the nature of the visit.

LPA began the tour of the facility accompanied by caregiver. The facility currently has 5 residents in care. LPA observed upon entry 2 resident in living room and 1 resident in dinning room. All residents in facility appeared well taken care of. LPA spoke with alert resident during the tour regarding the quality of their care. Facility appears clean and sanitary. LPA observed in the main entry a check in station per covid guidelines. Facility staff screens all visitors, staff and residents. Facility keeps documentation in regard to covid for all the visitors, staff and residents. At 10:20am the hot water temperature was tested in bathrooms which are used by the residents. The hot water temperature was measured at 114.1 Fahrenheit degrees. LPA observed facility has covid precautionary postings through out the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of all residents in care. LPA observed an ample supply of emergency food and water. First aid kit was observed to be stored with medication. LPA observed facility has PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and in all common spaces. LPA toured the outside and observed a shaded outside space for residents. Area is used for outdoor visitation as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are currently 2 private and 2 shared for residents.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Facility Representative and a copy of this report was provided and left at the facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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