306000415-8-16-2022-22-AS-CDPO-CHCTE5-20220816143923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000415
Report Date: 08/16/2022
Date Signed: 08/16/2022 02:39:29 PM

Document Has Been Signed on 08/16/2022 02:39 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:	OASIS HOME FOR THE ELDERLY		FACILITY NUMBER:	306000415
ADMINISTRATOR:	FORERO, CRISTO A.		FACILITY TYPE:	740
ADDRESS:	23471 BLUE BIRD DRIVE		TELEPHONE:	(949) 454-9188
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	4	CENSUS: 3	DATE:	08/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Administrator - Olga Moreno		TIME COMPLETED:	02:50 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 was greeted and granted entry by staff on duty. During the visit, 2 staff were on duty, which included facility administrator (AD) Olga Moreno. As of 8/16/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA De Perio observed the Administrator's Certificate for Olga Moreno, which expires on 12/18/22. LPA De Perio toured the interior and exterior portions of the facility with AD Moreno. The facility is a two level structure. NOTE: second level is for staff use, NOT for resident use. LPA De Perio verified and observed that there are no residents residing on the second floor. Facility is licensed for 4 non-ambulatory, 0 bedridden and 1 hospice. Currently, there are a total of 3 residents in care, of which 1 is on hospice, 0 bedridden. There are a total of 2 shared bedrooms, which all 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 is one restroom that is shared among the residents, of which was observed to be in good repair, toilet was operational, and grab bar and non-skid floor mat was provided. Water temperature in restroom was measured to be at 120.0 degrees Fahrenheit and a hand washing sign was also posted in restroom. 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 and located in the kitchen and garage.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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: OASIS HOME FOR THE ELDERLY	FACILITY NUMBER: 306000415
	VISIT DATE: 08/16/2022

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LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway. 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 and by the facility entrance. Medications were locked in a cabinet located in the kitchen. 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 one exit gate in the backyard, which was self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Moreno. 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 Moreno to review, print 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.

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 Moreno 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 Moreno and a copy of this report was 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: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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