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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002068
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:50:35 AM


Document Has Been Signed on 08/03/2022 11:50 AM - 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: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: 1DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Elvira Bathan, House ManagerTIME COMPLETED:
11:50 AM
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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 Elvira Bathan and explained the nature of the visit. This facility is licensed to provide services to 6 Non-Ambulatory Residents, and has a hospice waiver for three (3) residents. There is currently no resident receiving hospice care services at this time. LPA Quiroz called and spoke to Administrator (AD) Vivian Ortiz upon arrival to the facility. AD Ortiz indicated not being able to attend today's inspection visit due to a planned scheduled personal appointment. AD Ortiz has an Administrator Certificate with expiration date of 9/8/2023.
On or about 11:01am, LPA Quiroz along with House Manager Elvira Bathan toured the inside and outside of facility. There is one resident in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz interacted with one resident in care. 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 in garage area. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment.
During today's inspection visit, LPA Quiroz reviewed one of one resident records. Facility indicated staff and resident have been fully vaccinated for COVID-19 and boostered.
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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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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