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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001232
Report Date: 02/28/2022
Date Signed: 02/28/2022 11:57:27 AM


Document Has Been Signed on 02/28/2022 11:57 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:MEMORY LANE ELDERLY CAREFACILITY NUMBER:
306001232
ADMINISTRATOR:BORDUZ, FLAVIA & GHEORGHEFACILITY TYPE:
740
ADDRESS:2507 W. KEYS LANETELEPHONE:
(714) 484-6639
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 1DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Staff Flavia BorduzTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. LPA met with Staff Flavia Borduz and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden; and hospice waiver for two. for this visit, there was one resident under hospice care.

About 10;50 AM, LPA Marin toured the interior and interior portions of the facility. LPA observed one resident in care and one staff member on the floor. There were three private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid-floor mat. Hot water was measured at 120 degrees Fahrenheit. 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 extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Side exit doors were self closing and self latching. LPA Marin reviewed the COVID 19 mitigation plan of the facility.

For this visit,no citation has been issued.

LPA Marin conducted an exit interview with Ms. Borduz and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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