306002068-9-20-2021-22-AS-RQUZ-C72T2U-20210920142120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002068
Report Date: 09/20/2021
Date Signed: 09/20/2021 02:21:24 PM

COMPREHENSIVE INSPECTION

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 CARE		FACILITY NUMBER:	306002068
ADMINISTRATOR:	VIVIAN ORTIZ-LUIS		FACILITY TYPE:	740
ADDRESS:	17688 SAN FRANCISCO STREET		TELEPHONE:	(714) 963-0026
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 4	DATE:	09/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Elvie Bathan (House Manager) and Ofelia Depusoy, (Live in Caregiver)		TIME COMPLETED:	02:22 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 House Manager Elvie Bathan and explained the nature of the visit. This facility is licensed to provide services 6 Non-Ambulatory Residents, and has a hospice waiver for three (3) residents. Administrator (AD) AD Vivian Ortiz has an Administrator Certificate with expiration date of 09/08/2021. LPA Quiroz called and spoke to AD Ortiz upon arrival to facility. AD Ortiz indicated not being able to attend today's inspection visit due to a planned scheduled personal appointment. AD Vivian indicated she already completed Administrator Certificate renewal and currently awaiting for new certificate. AD Ortiz agreed to submit a copy of Administrator Certificate with new expiration date upon receiving new Adminsitrator certificate.

On or about 12:55pm LPA Quiroz along with House Manager Elvie Bathan toured the inside and outside of facility. Two staff working at facility were observed to be wearing face masks upon arrival to facility. There are four residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz interacted with four of four residents in care. LPA Quiroz observed one resident in backyard area sitting on chair under shaded area and three residents in their bedrooms 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. Facility is taking temperatures daily and documenting 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. Facility has completed the LIC808 Mitigation plan and LPA Quiroz approved the plan on today’s visit.

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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: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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: FOUNTAIN VIEW BOARD AND CARE	FACILITY NUMBER: 306002068
	VISIT DATE: 09/20/2021

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During today's inspection visit, LPA Quiroz reviewed four of four resident records and staff and residents vaccination records. Two of two staff and three of four staff have been fully vaccinated for COVID-19.

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 Administrator Ortiz via telephone, and with House Manager Bathan during today's visit, and a copy of this report was provided to Facility staff at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC809 (FAS) - (06/04)

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