306001518-9-25-2024-22-AS-ARJR-D9FTWL-20240925150542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001518
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:05:48 PM

Document Has Been Signed on 09/25/2024 03:05 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	A PIECE OF HEAVEN		FACILITY NUMBER:	306001518
ADMINISTRATOR:	CELIA RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	23191 TULIP STREET		TELEPHONE:	(949) 586-9235
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 3	DATE:	09/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:27 PM
MET WITH:	Lorenia Servin-Caregiver, Celia Rodriguez-Administrator		TIME COMPLETED:	03:20 PM

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Lorenia Servin. Administrator (AD) Celia Rodriguez arrived shortly after.

For today’s visit, LPA observed a total of three residents in care and two staff members on duty.

LPA observed the Administrator's Certificate for Celia Rodriguez which expired on May 17 2024, however, AD provided proof of payment to show that the certificate is in renewal process. Renewed certificate has not yet been received and is pending. LPA reminded Licensee to post certificate once received.

LPA Ramirez toured the interior and exterior portions of the facility with AD Rodriguez. The facility is a two-story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of six bedrooms, of which three are resident bedrooms, and three are bedrooms for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested 107.2 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the dining room and one in the garage.

CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A PIECE OF HEAVEN	FACILITY NUMBER: 306001518
	VISIT DATE: 09/25/2024

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LPA observed the emergency disaster and evacuation plan which is located by dining room. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

During today's visit LPA observed residents relaxing in their bedroom watching television and/or walking throughout the facility.

LPA reviewed resident and staff files. LPA interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA Ramirez advised AD Rodriguez to use the general email address:

CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Rodriguez.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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