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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000910
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:51:35 PM


Document Has Been Signed on 04/08/2022 03:51 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:VALLEY RESIDENTIAL ELDERLY CAREFACILITY NUMBER:
306000910
ADMINISTRATOR:ELVIRA GOMEZFACILITY TYPE:
740
ADDRESS:24911 ADELANTOTELEPHONE:
(949) 249-9092
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:David Molina TIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Administrator David Molina. LPA explained the reason for the visit. LPA and Administrator toured the facility. Facility has 6 bedrooms (1 is for staff only), 5 bathrooms, living room, dining room, kitchen and a 2 car garage used for storage. LPA observed the fireplace in the living room is not screened. LPA observed the PUB 475 poster (See Something, Say Something poster) is the correct size and mounted in the entrance of the facility. LPA observed the fireplace in the family room is screened. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPA observed the cleaning supplies are kept locked under the sink. LPA observed sharp objects including knives are kept locked in a kitchen drawer. LPA observed all resident rooms had the required furnishings. All bathrooms are clean and operational. Hot water measured 108.0 degrees Fahrenheit to 114.0 degrees Fahrenheit. LPA observed all medication is kept locked in a closet. The garage is kept locked and inaccessible to residents. LPA observed extra furniture, supplies and food stored in the garage. LPA and Administrator toured the backyard. LPA observed 3 separate shaded seating areas for residents. LPA observed a six foot tall water fountain with 3 levels. The depth of the water is around 1 inch. The lowest level of the fountain is around 2 1/2 feet high. The exit gate is latched and operational. No obstacles or hazards observed in the backyard. Smoke detectors/carbon monoxide detectors tested operational. Facility has a mitigation plan that is pending review. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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