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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002068
Report Date: 04/15/2021
Date Signed: 04/15/2021 12:40:23 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:FOUNTAIN VIEW BOARD AND CAREFACILITY NUMBER:
306002068
ADMINISTRATOR:VIVIAN ORTIZ-LUISFACILITY TYPE:
740
ADDRESS:17688 SAN FRANCISCO STREETTELEPHONE:
(714) 963-0026
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 4DATE:
04/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Wais YousafiTIME COMPLETED:
12:40 PM
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Licensing Program Analysts (LPAs) Ruth Martinez is conducting this tele-visit case management for the purpose of a health and safety check. Tele-visit is being conducted due to COVID-19 and for pre-cautionary measures. LPA spoke to Wais Yousafi, Administrator and explained the nature of the visit.

During the case management visit LPA took a tour of the inside of the facility, restrooms, and common areas. LPA observed there was two caregivers in the facility. LPA observed three resident in their rooms and one resident watching TV. LPA observed that food storage areas are well organized. LPA inspected food supply adequate amount was observed to be within regulations. The facility has a two-day supply of perishables and seven-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction. There are no health and safety concerns observed in the facility.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with facility representative via tele-visit and a copy of this report was provided to facility representative via email. An electronic email read receipt or response to email indicating as received as confirmation. Facility representative agrees to send a signed copy by email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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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