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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001291
Report Date: 03/22/2022
Date Signed: 03/22/2022 01:43:24 PM


Document Has Been Signed on 03/22/2022 01:43 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:KARRY'S ELDER CAREFACILITY NUMBER:
306001291
ADMINISTRATOR:CAMPBELL, KARRYFACILITY TYPE:
740
ADDRESS:25392 CHAMPLAIN RD.TELEPHONE:
(949) 855-4757
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:3CENSUS: 1DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Karry CampbellTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility. LPA met with Karry Campbell, Administrator and explained the nature of the visit.

LPA Martinez accompanied by Administrator began the tour of the inside and outside of the facility. There is one resident in care and there are no active covid-19 cases in facility. LPA was informed that resident is at day program. LPA observed required department postings, covid-19 precautionary postings throughout the facility. All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected resident bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. Resident bedrooms are all private bedrooms with one resident per. LPA observed a check in station in the main entry of the facility. Facility is taking temperature daily and documenting the results. Facility has the back-up emergency food and water supply as well as PPE supplies in the facility. LPA toured the outside of the facility and observed several shaded seating areas for resident’s enjoyment. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed and approved by the Department on April 14, 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 the 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: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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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