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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000870
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:31:29 PM

Document Has Been Signed on 03/10/2022 04:31 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:QUAIL HOMEFACILITY NUMBER:
306000870
ADMINISTRATOR:RAFAEL A. TORRESFACILITY TYPE:
735
ADDRESS:128 N. QUAIL LANETELEPHONE:
(714) 639-6947
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 4DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Marcelina Lived, caregiver
Eliezer Lived, caregiver
Rafael Torres, Administrator (via phone)		TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregiving staff Marcelina Lived and Eliezer Lived after explaining the purpose of the visit and being asked to sign in. Staff called Administrator Rafael Torres to notify him of the visit. Administrator was unable to assist with visit in person but was able to go over the Infection Control domain questions with LPA.

At approximately 4:05pm, LPA accompanied by caregivers began the tour of the facility. There are currently four (4) clients in care. Clients are observed relaxing in their bedrooms or in the common areas and appears well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. The four bedrooms are observed to have all required components and bathrooms observed are equipped with grab bars and slip mats.
LPA observed a check-in station next to the entrance of the facility where temperature checks are being documented for visitors. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs posted throughout. Water temperature is measured at 107F and 112F in the clients' bathrooms. The facility has completed and submitted their LIC808 Mitigation Plan on 02/09/2021.
LPA observed a sufficient supply of food and water. A 30-day supply of medication is stored and locked in a kitchen cabinet. Facility has an adequate supply of PPE. LPA toured the outside of the facility. Outdoor furniture is present for the clients' enjoyment. Outside space is free of clutter and debris. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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