306001926-10-29-2021-22-AS-RQUZ-C89QFG-20211029120754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001926
Report Date: 10/29/2021
Date Signed: 10/29/2021 12:07:59 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:	COWAN HEIGHTS HOME CARE		FACILITY NUMBER:	306001926
ADMINISTRATOR:	ELENA COCA		FACILITY TYPE:	740
ADDRESS:	19080 SMILEY DR.		TELEPHONE:	(714) 538-5219
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 4	DATE:	10/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Elena Coca, Licensee/Administrator		TIME COMPLETED:	12:12 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 and granted entry into the facility by Licensee/Administrator (L/AD) Elena Coca 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; of which 6 may be bedridden and has a hospice waiver for three (3) residents. L/AD Elena Coca has an Administrator Certificate with expiration date of 07/30/2023.

On or about 11:05am LPA Quiroz along with L/AD Elena Coca toured the inside and outside of facility. There are four residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed three (3) residents in living-room area resting watching television, and one (1) resident was observed in his bedroom resting watching television. Four of four 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 Elena indicated facility is taking temperatures daily; however not documenting results. L/AD Elena Coca agreed to commence documenting temperature 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.

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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: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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: COWAN HEIGHTS HOME CARE	FACILITY NUMBER: 306001926
	VISIT DATE: 10/29/2021

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Facility has completed the LIC 808 Mitigation plan dated 3/21/2021. During today's visit, LIC 808 Mitigation Plan dated 3/6/2021 was approved.

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

During today's visit, L/AD Elena Coca indicated due to personal reasons, she will be taking a break from operating services due to medical reasons. Four of four resident's families were notified about L/AD's medical reason request, and currently looking for placement. 2 of 4 resident's families have found placement and 2 of 4 resident's are still looking for placement and working with a referral agency.

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.

This report was reviewed with L/AD Elena Coca, and a copy of this report 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: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC809 (FAS) - (06/04)

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