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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613018
Report Date: 05/09/2022
Date Signed: 05/09/2022 01:58:17 PM

Document Has Been Signed on 05/09/2022 01:58 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:DISTOR'S RESIDENTIAL CARE IIFACILITY NUMBER:
300613018
ADMINISTRATOR:LORI COOKFACILITY TYPE:
735
ADDRESS:23456 WHITE DOVETELEPHONE:
(949) 587-9380
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lori Cook, AdminsitratorTIME COMPLETED:
02:30 PM
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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 advised caregiver the reason for the visit. Administrator arrived shortly after and met with LPA.

LPA began the tour of the facility accompanied by Administrator. The facility currently has 3 clients in care. LPA observed one client in dining room and remainder of clients were out in the community. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the visitors, staff and clients. LPA observed facility has covid precautionary posting throughout the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of residents in care. LPA inspected clients bedrooms and they appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed the emergency food supply and water. Facility has a supply of PPE and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA toured the outside and observed a shaded outside space for clients. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed by the Department and approved on July 27, 2021.

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

This report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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