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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002173
Report Date: 02/03/2022
Date Signed: 02/03/2022 03:32:04 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:ARBOR VIEWFACILITY NUMBER:
306002173
ADMINISTRATOR:FISK, MARK & ERINFACILITY TYPE:
740
ADDRESS:26851 LA SIERRA DRIVETELEPHONE:
(949) 295-9191
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Administrator Mark FiskTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. LPA met with Administrator (AD) Mark Fisk and stated the purpose of this visit.

The facility is a two-level structure and licensed for 6 non-ambulatory and with hospice waiver for three. For this visit there were two residents under hospice care.

About 11:27 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were five residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were four private and one shared resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 120 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. Upper level holds staff room and facility office. Call system for residents was tested to be operational. For the exterior portion, facility had patio furniture in good repair. Grounds were free of tripping hazards. Side exit door was self-latching and self-closing. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed with AD the latest visitation requirements as required by State Public Health Officer Order issued on December 31, 2021.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD M. Fisk; and copy of this report was left in the facility.

*** This is an amended report ***
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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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