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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002241
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:29:10 PM


Document Has Been Signed on 05/17/2022 03:29 PM - 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:HARBOR VIEW ESTATEFACILITY NUMBER:
306002241
ADMINISTRATOR:VILMA B. MANUELFACILITY TYPE:
740
ADDRESS:3911 CALLE MAYOTELEPHONE:
(949) 661-6874
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Vilma ManuelTIME COMPLETED:
02:42 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Rafael Imbisan and Administrator Vilma Manuel and explained the reason for the visit. Administrator Vilma Manuel has an administrator certificate expiring on 03/07/2024.

At 1:10 PM, LPA toured the facility with Administrator Manuel. Facility has 6 residents in care during today's visit with 4 on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Residents participate in activities such as exercise. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident and staff temperatures daily and documents. Facility staff are wearing masks during today's visit. Facility has covid precaution postings as well as all required department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved and posted in the facility as well as the emergency disaster plan. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed multiple shaded outside visitation areas. Exit gates are unlocked and self latching. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six resident files during the visit and all files are up to date including emergency information. All residents and staff are vaccinated for Covid-19.

LPA consulted with Administrator on the importance of reviewing physician reports for accuracy.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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