<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000889
Report Date: 12/21/2021
Date Signed: 12/21/2021 01:10:42 PM

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:SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CAFACILITY NUMBER:
306000889
ADMINISTRATOR:JO DEE GIBSONFACILITY TYPE:
741
ADDRESS:16850 E. BASTANCHURY ROADTELEPHONE:
(714) 577-9281
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:76CENSUS: 36DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jo Dee Gibson, Executive DirectorTIME COMPLETED:
01:15 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), Kathrina Chin conducted an unannounced visit for the purpose of conducting a required annual visit. LPA were greeted by Lida Spicer, LVN, and Espi Naakgeboren, Assistant Administrator and met with Jo Dee Gibson, Administrator and explained the purpose of the visit.

LPA toured the facility. There are 36 residents residing in the facility and no active COVID-19 cases. All residents appeared clean and well taken care of. LPA observed required postings in the facility as well as hand washing signs in the restrooms. All bathrooms observed had ample soap/sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. LPAs observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. LPA reviewed the COVID-19 mitigation plan of the facility.

Smoke detectors, carbon monoxide and auditory exit alarms were tested and were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 116.2 and 110.2 degrees Fahrenheit as observed in two apartment units. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguishers were mounted and charged. For the exterior portion, facility had multiple patio furniture in good repair and a several covered patio, and grounds were free of tripping hazards.


No deficiencies cited this review as per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1