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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606831
Report Date: 07/07/2022
Date Signed: 07/07/2022 03:58:17 PM


Document Has Been Signed on 07/07/2022 03:58 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:FREEDOM VILLAGEFACILITY NUMBER:
300606831
ADMINISTRATOR:MARIANNE CASINO/ J.NIBLETTFACILITY TYPE:
741
ADDRESS:23442 EL TORO ROADTELEPHONE:
(949) 472-4733
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:533CENSUS: 59DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Joel NiblettTIME COMPLETED:
01:42 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Celine DePero conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Administrator Joel Niblett and explained the reason for the visit. Assistant Director Jackie Arreaga and Clinical Director Jean Guevara was present as well. Administrator Joel Niblett has an administrator certificate expiring on 08/15/2023.
At 11:05 AM, LPAs toured the facility with the management team. Facility is a three level building with skilled nursing on the first floor. Facility has a library, beauty salon, and multiple visitation areas. Facility has 59 residents in care during today's visit with seven on hospice care. LPAs observed residents relaxing in common areas of the facility as well as in their rooms. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a hand written visitor sign in sheet as well as a self temperature taking station. Facility takes resident temperatures daily and documents. Facility has all required department postings. Facility has a mitigation plan as well as the facility's Covid-19 prevention plan. Quick Response Fire Protection conducted a fire inspection on 03/29/2022 and facility tests smoke detectors in-house monthly. LPAs observed ample emergency food and water as well as multiple first aid kits throughout the facility. Facility has sanitation stations spread out through the common areas. Resident's participate in activities such as exercise, games, and music therapy. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. Facility rooms are currently single occupancy. LPAs reviewed select resident files and files were complete.

Based on the observations made during today’s visit, NO deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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