300613094-11-18-2021-22-AS-RQUZ-C8VTG8-20211118134243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613094
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:42:51 PM

COMPREHENSIVE INSPECTION

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:	OTILIA'S BOARD AND CARE		FACILITY NUMBER:	300613094
ADMINISTRATOR:	KOVAC, OTILIA		FACILITY TYPE:	740
ADDRESS:	24251 BARK STREET		TELEPHONE:	(949) 951-1433
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	11/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:39 PM
MET WITH:	Olivia Kovac, Administrator		TIME COMPLETED:	01:56 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by caregiver and met with Administrator (AD) Olivia Kovac and explained the nature of the visit.

This facility is licensed to provide services to residents age range 60 and over, 6 Non-Ambulatory Residents; and has a hospice waiver for four (4) residents. AD Olivia Kovac has an Administrator Certificate with expiration date of 03/19/2023.

On or about 1:01pm, LPA Quiroz along with AD Olivia Kovac toured the inside and outside of facility. There are five (5)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed one (1) resident eating her lunch in seating dining-room, (4) four residents were observed in their bedrooms eating their lunch meal. LPA Quiroz observed today's lunch to be chicken and rice, juice of choice, coffee/tea and substitute chicken sandwich was offered. Five of five residents present in the facility appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. AD Olivia Kovac indicated facility is taking temperatures daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed ample seating area with tables and chairs for resident’s enjoyment in backyard area and front porch area.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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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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: OTILIA'S BOARD AND CARE	FACILITY NUMBER: 300613094
	VISIT DATE: 11/18/2021

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Facility has completed the LIC 808 Mitigation plan dated 3/15/2021. The LIC 808 Mitigation Plan was approved by LPA Quiroz during today's visit.

During today's inspection visit, AD Olivia Kovac indicated "All residents are fully vaccinated for COVID-19 and working on coordinating booster shots." LPA Quiroz reviewed 5 of 5 resident's records during today's visit.

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 AD Kovac, and a copy of this report and LIC 811 were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC809 (FAS) - (06/04)

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