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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000929
Report Date: 03/25/2022
Date Signed: 03/25/2022 10:32:09 AM


Document Has Been Signed on 03/25/2022 10:32 AM - 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:LEISURE LIVING IIFACILITY NUMBER:
306000929
ADMINISTRATOR:SOPHIE TOOCHINDAFACILITY TYPE:
740
ADDRESS:24182 MCCOY RD.TELEPHONE:
(949) 583-1996
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Sophie ToochindaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by caregiver and granted entry. LPA advised caregiver the reason for today’s visit. Sophie Toochinda, Administrator arrived shortly after and met with LPA.

LPA began the tour of the inside and outside of the facility. The facility currently has six residents in care and no active Covid-19 case in the facility. Upon entry LPA observed five residents having breakfast and one resident in their bedroom. All resident appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the main entry of the facility. LPA observed facility to have Covid precautionary postings throughout the facility as well as all required Department postings. Facility has an active Covid-19 prevention plan in place for the safety of residents in care. LPA observed a supply of emergency food and water as well first aid kits in the facility. Facility has a supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place throughout the facility and all common spaces. LPA toured the outside and observed a shaded seating space for resident’s enjoyment. Facility has a plan for Covid testing residents and staff as needed as well as a plan for isolation as needed. The facility has completed the LIC808 Mitigation Plan. Plan was reviewed and approved by the Department on May 13, 2021.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with 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: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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