306002536-8-10-2022-22-AS-RQUZ-CH6PW5-20220810114011

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002536
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:40:15 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/10/2022 11:40 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:	CARE OF HEART FOR ELDERLY IN ORANGE		FACILITY NUMBER:	306002536
ADMINISTRATOR:	MYRNA ADRIANO		FACILITY TYPE:	740
ADDRESS:	3342 E. MAPLE AVENUE		TELEPHONE:	(714) 633-4607
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 3	DATE:	08/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Myrna Adriano, Licensee/Administrator		TIME COMPLETED:	11:45 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

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, COVID-19 screened and granted entry into the facility by Caregiver Carolyn Nuestro. LPA Quiroz met with Licensee/Administrator (L/AD)Myrna and explained the nature of the visit. Facility indicated screening all incoming visitors prior to entering the facility. This facility is licensed to provide services to five (5) Non-Ambulatory Residents with one (1) bedridden , and has a hospice waiver for four (4) residents. Facility is currently providing hospice services to (1) one resident at this time. Administrator (AD)Myrna Adriano has an Administrator Certificate with expiration date of 3/3/2023.

On or about 10:17am, (L/AD) LPA Rosie Quiroz along with began the tour of the inside and outside of the facility. There are three (3) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed two of three residents in their bedroom resting, and one of three residents out for a walk with caregiver supervision. LPA Quiroz interacted and interviewed with resident's during today's visit. Three of three residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 83 degrees fahrenheit. L/AD Adriano indicated "Each room has their own air conditioner, and residents can control it."

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within normal limits. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and kitchen area readily available for staff and residents.

Continued on next page...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: CARE OF HEART FOR ELDERLY IN ORANGE	FACILITY NUMBER: 306002536
	VISIT DATE: 08/10/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Quiroz toured the outside of the facility and observed seating and shaded area for residents and visitor's enjoyment in backyard area. LPA Quiroz observed locked and secured empty swimming pool area during today's visit. L/AD Adriano indicated, "The residents don't use the swimming pool area only the shaded area where table and chairs are located."

LPA Quiroz was informed that two of three residents and two staff have had their COVID-19 vaccinations and two boosters. Facility indicated to be recording resident's temperatures three times daily.

During today's visit, LPA Quiroz provided Consultation on Title 22 and ongoing COVID-19 Infection control and indoor facility temperature during hot weather season throughout today's visit. 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 (L/AD) Myrna Adriano, and a copy of this report and LIC 811 Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2