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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000578
Report Date: 10/14/2021
Date Signed: 10/14/2021 10:38:09 AM

Document Has Been Signed on 10/14/2021 10:38 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:FORDVIEW HOMEFACILITY NUMBER:
306000578
ADMINISTRATOR:MARITES T. DE VERAFACILITY TYPE:
735
ADDRESS:24372 FORDVIEW STREETTELEPHONE:
(949) 916-7233
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Marites De Vera, AdministratorTIME COMPLETED:
10:47 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver. LPA met with Marites De Vera, Administrator and explained the nature of the visit.

LPA Martinez accompanied by Administrator began the tour of the inside and outside of the facility. There are four clients in care and there are no active covid-19 cases in the facility. LPA observed two clients taking their zoom classes in the dinning room, and one client in their bedroom. All clients appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All bathrooms observed to have ample supply of soap and appeared to be clean. LPA inspected client’s bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking client and staff temperature daily and documenting the results. LPA observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as ample supply of PPE. LPA toured the outside of the facility and observed a shaded seating area for the client’s enjoyment. The facility has completed the LIC808 Mitigation Plan and was approved by the Department on July 28, 2021.

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 the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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