306000578-10-7-2022-22-AS-CDPO-CJYQ77-20221007115440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000578
Report Date: 10/07/2022
Date Signed: 10/07/2022 11:54:52 AM

Document Has Been Signed on 10/07/2022 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	FORDVIEW HOME		FACILITY NUMBER:	306000578
ADMINISTRATOR:	MARITES T. DE VERA		FACILITY TYPE:	735
ADDRESS:	24372 FORDVIEW STREET		TELEPHONE:	(949) 916-7233
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	10/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator - Marites De Vera		TIME COMPLETED:	12:15 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, there was one staff on duty, who contacted facility administrator (AD) Marites De Vera about visit. As of 10/7/22, 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 in the hallway of the facility. LPA De Perio observed the Administrator's Certificate for Marites De Vera which expires on 3/20/2024. LPA De Perio toured the interior and exterior portions of the facility with staff on duty (S1). The facility is a two level structure and is licensed for 6 ambulatory clients, however Regional Center has vendored the facility for 4 clients. Currently, there are a total of 4 clients in care. On the first level, there are a total of 6 bedrooms of which 3 are for staff, and 1 shared room for clients and there are two 2 single rooms for clients. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. On the second level, there are two bedrooms which are utilized for AD's family. LPA De Perio observed and verified that the second level is not for client use and observed no clients residing on the second floor. LPA De Perio also conducted file reviews to confirm that live-in family members have been cleared and completed a background check.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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: FORDVIEW HOME	FACILITY NUMBER: 306000578
	VISIT DATE: 10/07/2022

NARRATIVE

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Smoke and carbon monoxide detector were tested and operational. There are a total of 3 restrooms in the facility of which were observed to be in good repair, and toilets were operational. Water temperature in restrooms were measured at 106.2 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients 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 in the facility hallway. Facility had back-up emergency food and water supply, located in the garage.

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.
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 and located in the hallway cabinet. Toxins were also observed to be locked and inaccessible to clients in care. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD De Vera. 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.

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

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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: FORDVIEW HOME	FACILITY NUMBER: 306000578
	VISIT DATE: 10/07/2022

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LPA De Perio discussed with AD De Vera 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 85075.4 Observation of the Client and Sections 80061 and 85061 Reporting Requirements with AD De Vera.

LPA De Perio advised AD De Vera 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 De Vera and a copy of this report, and copies of the regulations discussed were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

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