<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001960
Report Date: 07/07/2022
Date Signed: 07/07/2022 05:37:49 PM


Document Has Been Signed on 07/07/2022 05:37 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ECLC - WAKE FOREST VILLAFACILITY NUMBER:
306001960
ADMINISTRATOR:ANGELITA DAVIDFACILITY TYPE:
740
ADDRESS:233 WAKE FOREST RD.TELEPHONE:
(714) 434-9489
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Angelita DavidTIME COMPLETED:
05:50 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 Analyst (LPA) Jessica Cho conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 3:18 pm, LPA was greeted and granted entry by Administrator (Admin) Angelita David and stated the purpose of the visit. Upon entry, LPA completed the Coronavirus 2019 (COVID-19) screening procedure. There are no active COVID-19 cases present as of today. Admin stated that the facility screens visitors but does not document temperatures on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and the entry way. The Residential Care for the Elderly (RCFE) Complaint Poster PUB 475 was posted in the dining room in the size of 8.5"x11," and the Administrator's Certificate for Angelita David expires on 7/16/2023.

At 3:33 pm, LPA toured the interior and exterior portions of the facility with the Admin. The facility is a single level structure and licensed for six non-ambulatory; and has a hospice waiver for three residents. Currently, there a total of four residents in the facility of which one is in hospice care. Facility appeared clean and sanitary in all observed areas. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxides, and auditory exit alarms tested operational. The restrooms observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water measured at 117.1 degrees Fahrenheit in Resident Restrooms #1 and #2, and 119.1 degrees Fahrenheit in Resident Restroom #3. LPA did not observe hand washing signs in three resident and one staff restrooms. Paper towels and hand soaps were provided. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. The fire extinguishers were charged and mounted in the dining and living room. For the exterior portion, LPA observed patio furniture under a lattice, and the grounds were free of tripping hazards. The outdoor shed was locked and stored PPE and incontinence supplies. The side gates were self-closing and self-latching.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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 6


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: ECLC - WAKE FOREST VILLA
FACILITY NUMBER: 306001960
VISIT DATE: 07/07/2022
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
LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly, Community Care Facilities and Child Care Centers LIC 610 dated 5/6/2021. Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility had back-up emergency food and water supply stored in the garage. The facility had sufficient PPE and incontinence supplies stored in the outdoor shed. The First Aid Kit met all the required components except the First Aid Manual which was published by the American Red Cross in 1994.

LPA consulted the following: to document all visitor's temperatures, to post hand washing signs in all resident/staff restrooms, to revise and update on the Emergency Disaster Plan for Residential Care Facilities for the Elderly LIC 610E, to enlarge the Complaint Poster PUB 475 in the Department size requirement of 20"x26," and to purchase the current edition of the First Aid Manual approved by the American Red Cross, American Medical Association, or a state or federal health agency.



LPA reviewed the approved COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Angelita David, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6