300613094-10-10-2022-22-AS-CDPO-CK3RER-20221010125757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613094
Report Date: 10/10/2022
Date Signed: 10/10/2022 12:58:08 PM

Document Has Been Signed on 10/10/2022 12:58 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:	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: 4	DATE:	10/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Facility Administrator - Olivia Kovac		TIME COMPLETED:	01:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 1 staff was on duty, who contacted facility administrator (AD) Olivia Kovac about visit. As of 10/10/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA observed the Administrator's Certificate for Olivia Kovac, which expires on 2/19/2023 and Jennifer Pop which expires on 3/19/2023. LPA De Perio toured the interior and exterior portions of the facility with AD Kovac. The facility is a 2 level structure and is licensed for 6 non-ambulatory residents, 0 bedridden and 4 hospice. For this visit, there are a total of 4 residents in care, 0 on hospice, 0 bedridden. There are a total of 6 bedrooms, of which all are private rooms. LPA De Perio toured the second level of the facility which is designated only for the use of AD Kovac. LPA De Perio observed and verified that the second level is not for resident use. Second level consists of 3 bedroom, 2 bathroom and 1 kitchen. On the first level, LPA De Perio 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 5 restrooms on the first floor. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 107.8 degrees Fahrenheit and hand washing signs were also posted in each restroom.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

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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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: 10/10/2022

NARRATIVE

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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 extinguisher was charged, mounted and located in the kitchen.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in a cabinet located under the stairs. Toxins were also observed to be locked and inaccessible to residents.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is 1 exit gate in the backyard, which is self-closing and self-latching. No bodies of water were observed. LPA De Perio observed a shed in the backyard that is locked and utilized for storage.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Kovac. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Kovac to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Kovac.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 10/10/2022

NARRATIVE

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

LPA De Perio advised AD Kovac to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Kovac and a copy of this report and copies of the regulations discussed were provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC809 (FAS) - (06/04)

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