306001518-9-6-2022-22-AS-CDPO-CHZP82-20220906110449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001518
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:04:55 AM

Document Has Been Signed on 09/06/2022 11:04 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:	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: 4	DATE:	09/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Facility Administrator-Celia Rodriguez		TIME COMPLETED:	11:25 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Celia Rodriguez who checked temperature prior to entering facility. As of 9/6/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted in throughout of the facility. The PUB475 "See Something, Sa Something" poster was also observed at the entrance of the facility. LPA observed the Administrator's Certificate for Celia Rodriguez, which expires on 5/17/2024. LPA De Perio toured the interior and exterior portions of the facility with AD Rodriguez. The facility is a two level structure and is licensed for 6 non-ambulatory, 0 bedridden and 4 hospice. LPA De Perio toured the second level of facility and observed no residents residing on the second level and verified that second level is not for resident use. For this visit, there are a total of 4 residents in care, of which 2 are on hospice, and 0 bedridden. All 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. The restroom was observed to be in good repair, toilet was operational, and grab bars and non-skid floor mats were provided. Water temperature in restroom was measured to be at 105.3 degrees Fahrenheit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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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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: A PIECE OF HEAVEN	FACILITY NUMBER: 306001518
	VISIT DATE: 09/06/2022

NARRATIVE

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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 extinguisher was charged, mounted and located in the kitchen. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the hallway closet and in the garage. Medications were locked in the kitchen cabinet. Toxins were also observed to be locked in the garage and inaccessible to residents.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, both of which were self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Rodriguez. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Rodriguez to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

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

LPA De Perio advised AD Rodriguez to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Rodriguez and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

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