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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000712
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:08:25 PM


Document Has Been Signed on 03/30/2022 02:08 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:LOVING ELDERLY CARE HOMEFACILITY NUMBER:
306000712
ADMINISTRATOR:DIAZ, ELIZABETH E.FACILITY TYPE:
740
ADDRESS:24991 KATIE AVETELEPHONE:
(949) 588-1627
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 3DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Alejandro DiazTIME COMPLETED:
02:22 PM
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Licensing Program Analysts (LPAs) Ruth Martinez and Celine De Perio conducted an unannounced visit for the purpose of conducting a required annual inspection. LPAs was greeted and granted entry into the facility by Alejandro Diaz, Administrator and LPA explained the nature of the visit.

LPAs Martinez and De Perio accompanied by Administrator began the tour of the inside and outside of the facility. There are three residents in care and there is no active covid-19 case in the facility. LPAs observed three residents in the living room watching TV. All residents appeared to be clean and well taken care of. LPA observed a check in station in the main entry of the facility. LPA observed required Department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have ample supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed the emergency disaster and evacuation plan. Facility has the back-up emergency food and water supply as well as PPE supplies in the facility. LPAs toured the outside of the facility and observed a shaded seating area for resident’s enjoyment. The facility has completed the LIC808 Mitigation Plan, LPA Martinez reviewed and approved the plan on today’s visit. LPA emailed the signed and approved plan to the Administrator for their records.

Based on the observation made during today’s visit, no deficiencies were noted in the areas inspected 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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