306001789-1-7-2025-22-AS-ARJR-DCPRXZ-20250107122533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001789
Report Date: 01/07/2025
Date Signed: 01/07/2025 12:25:39 PM

Document Has Been Signed on 01/07/2025 12:25 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:	MOORE VILLAGE		FACILITY NUMBER:	306001789
ADMINISTRATOR/ DIRECTOR:	MINDY ANDREWS		FACILITY TYPE:	735
ADDRESS:	403 N. SUSAN STREET		TELEPHONE:	(714) 480-0025
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92703
CAPACITY: 42		CENSUS: 42	DATE:	01/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:21 AM
MET WITH:	Katharina Farmer Phan-Health Care Coordinator, Mindy Andrews-Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

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 Analysts (LPAs) Alvaro Ramirez, Jr. and Nancy Guillen conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Health Care Manager Katharina Farmer Phan. Administrator (AD) Mindy Andrews arrived shortly after.

For today’s visit, LPAs observed a total of 42 residents in care and eight staff member on duty.

LPAs toured the interior and exterior portions of the facility with Program Manager Vanessa Lopez. The facility is licensed for 42 ambulatory clients, of which five may be non-ambulatory. During today's visit LPAs toured buildings A-H, the gym, the recreational room, the kitchen, the dining room, the staff office/medication room and two laundry rooms. There are a total of 40 bedrooms. LPAs 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 detectors were tested and operational. There are a total of sixteen restrooms, of which fourteen are for client use. Restrooms were observed to be in good repair, toilets were operational, and grab bars were provided. Water temperature tested between 107.7 and 112.6 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 clients in care. Fire extinguishers were charged and one was located in each building. The fire extinguishers were last serviced on February 15, 2024.

During today's visit LPAs observed the residents doing their morning walk and having their morning meeting.

CONTINUED ON LIC809C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: MOORE VILLAGE	FACILITY NUMBER: 306001789
	VISIT DATE: 01/07/2025

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
26
27
28
29
30
31
32

LPAs observed the emergency disaster and evacuation plan which is located in each clients' building. Facility had back-up emergency food and water supply.

LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to clients in care. LPAs observed extra linen in the hallway of building G.

For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard. No bodies of water were observed.

LPAs reviewed four client files and four staff files. LPAs 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 advised AD Andrews 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 Andrews.

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

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2