300613094-10-24-2024-22-AS-ARJR-DACQ7A-20241024115450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613094
Report Date: 10/24/2024
Date Signed: 10/24/2024 11:54:54 AM

Document Has Been Signed on 10/24/2024 11:54 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:	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:	10/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Nicoleta Costea-Caregiver, Olivia Kovac-Administrator		TIME COMPLETED:	12:10 PM

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Nicoleta Costea and Administrator (AD) Olivia Kovac.

For today’s visit, LPA observed a total of five residents in care and two staff members on duty.

During today's visit LPA observed the AD certificate for AD Olivia Kovac which expires on February 19, 2025.

LPA toured the interior and exterior portions of the facility with AD Kovac. The facility is a two-story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and one bedridden. There are a total of nine bedrooms, of which six are resident bedrooms, and three are bedrooms for staff. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of seven restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 109.4-111.7 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the kitchen and one by the dining room.

During today's visit LPA observed as residents were having breakfast and watching television.

LPA observed the emergency disaster and evacuation plan which is located by dining room. Facility had back-up emergency food and water supply.

CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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: OTILIA'S BOARD AND CARE	FACILITY NUMBER: 300613094
	VISIT DATE: 10/24/2024

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LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed.

LPA reviewed five resident and three staff files. LPA interviewed residents and staff present.

During today's visit LPA consulted with AD regarding the updated Health Screening Report-Facility Personnel (LIC503). LPA informed AD to use the updated LIC503.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA advised AD Kovac to use the general email address:

CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Kovac.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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