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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002068
Report Date: 06/02/2021
Date Signed: 06/02/2021 03:20:36 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:
06/02/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Wais YousafiTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. LPA arrived at facility was greeted at the door by caregiver and granted entry. Upon entry caregiver took LPAs temperature and as COVID related questions to meet COVID guidelines. Four (4) residents currently reside at this location. LPA spoke with Vivian Ortiz-Luis Administrator and advised of visit. Shortly after Wais Yousafi arrived at facility and met with LPA.

Upon entry LPA observed there was one resident in living room and one caregiver in kitchen, one caregiver assisting resident and three residents remained in their rooms.

During the case management visit LPA took a tour of the inside and outside of facility, restrooms and common areas. LPA observed that the meal prepared appeared to be of good quality and storage area 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. At 3:13pm water temperature measured 120.2 Fahrenheit Degrees. There are no health and safety concerns observed in facility.

During the visit LPA was advised that water heater needed maintenance and plumber was scheduled to come within a week. LPA was advised water temperature fluctuates and water temperature is observed to stay within regulations.

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.

This report was reviewed with facility representative and a copy of this LIC809 report was left at facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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