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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000826
Report Date: 10/08/2021
Date Signed: 10/08/2021 01:59:27 PM

Document Has Been Signed on 10/08/2021 01:59 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:AURORA PALMSFACILITY NUMBER:
306000826
ADMINISTRATOR:CAROLYN DUNNFACILITY TYPE:
740
ADDRESS:28282 LA CALETATELEPHONE:
(949) 837-8494
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 4DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Rubina El-Alkaoui and Carolyn DunnTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Rubina El-Alkaoui and explained the reason for the visit. Caregiver Terrence Ferrer was present as well. Administrator Carolyn Dunn arrived during the visit. Administrator Carolyn Dunn has a current administrator certificate expiring on 06/29/2022.

At 11:54 PM, LPA toured the facility with Administrator Dunn. Facility has 4 residents in care during today's visit, with one on hospice. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. All rooms are currently single occupancy. Auditory exit alarms are operational. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident and staff temperatures daily and documents. Facility has covid precaution postings as well as department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water, PPE, and cleaning supplies. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gates are unlocked, self latching, and alarmed. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed four resident files during the visit and all files are up to date including emergency information. All residents and staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of posting the "Let Us No" poster in the entrance of the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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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