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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001789
Report Date: 02/16/2022
Date Signed: 02/16/2022 11:46:21 AM

Document Has Been Signed on 02/16/2022 11:46 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:MOORE VILLAGEFACILITY NUMBER:
306001789
ADMINISTRATOR:MINDY ANDREWSFACILITY TYPE:
735
ADDRESS:403 N. SUSAN STREETTELEPHONE:
(714) 480-0025
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 42CENSUS: 41DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mindy AndrewsTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Administrator Mindy Andrews. The focus of the visit was Infection Control. LPA toured the facility with Mrs. Andrews and the following was observed:
Covid signs were posted with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. LPA toured random living quarters on the property as well as the dining room. Hand sanitizing stations were present. Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed, having a snack and walking around the property. Social Distancing was observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication room for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review Department PINS for updates and changes in regards to visitation, dining, group activities, staff testing, resident testing and masking guidelines.

No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Mindy Andrews.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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