306001358-11-2-2021-22-AS-RQUZ-C8DUD2-20211102152850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001358
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:28:55 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:	PATCHWORK QUILT GUEST HOME FOR THE ELDERLY, THE		FACILITY NUMBER:	306001358
ADMINISTRATOR:	RIZALINA REYES		FACILITY TYPE:	740
ADDRESS:	23565 DURYEA DR.		TELEPHONE:	(949) 455-1326
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	11/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Rizalina "Sally" Reyes, Licensee/Administrator		TIME COMPLETED:	03:38 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Licensee/Administrator (L/AD) Rizalina Reyes and explained the nature of the visit.

This facility is licensed to provide services to residents age range 60 and over, 6 Non-Ambulatory Residents; and has a hospice waiver for four (4) residents. L/AD Rizalina Reyes has an Administrator Certificate with expiration date of 06/30/2023.

On or about 2:06pm LPA Quiroz along with L/AD Reyes toured the inside and outside of facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed five (5) residents in their bedroom resting watching television, five of five residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. L/AD Reyes indicated facility is taking temperatures daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment.

Facility has completed the LIC 808 Mitigation plan dated 1/09/2021. L/AD Reyes update changes to LIC 808 during today's visit. L/AD Reyes will resubmit LIC 808 to CCL for approval.

During today's inspection visit, L/AD Reyes indicated "all residents and staff at facility are fully vaccinated for COVID-19." LPA Quiroz reviewed 5 of 5 resident's records during today's visit.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PATCHWORK QUILT GUEST HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 306001358
	VISIT DATE: 11/02/2021

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CONTINUED...

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. (See LIC 9102- Technical Violation)

This report was reviewed with L/AD Rizalina Reyes, and a copy of this report, LIC 9102 and LIC 811 were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC809 (FAS) - (06/04)

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