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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002916
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:21:49 PM


Document Has Been Signed on 03/18/2022 03:21 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:ARC FACILITY AT CAMINO 2FACILITY NUMBER:
306002916
ADMINISTRATOR:MICHAEL ADAMSFACILITY TYPE:
740
ADDRESS:2209 CAMINO DEL SOLTELEPHONE:
(714) 870-5830
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Michael AdamsTIME COMPLETED:
03:35 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Michael Adams and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

During the inspection, LPA and AD observed there was 1 staff present, wearing PPE. LPA observed 6 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen, and observed they were organized. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

During the inspection, LPA and AD observed the following: in the living room, the fireplace does not have a screen; in the backyard, the pool gate was latched but did not have a lock.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA provided technical assistance regarding physical plant, storage, and N95 fit testing.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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 3


Document Has Been Signed on 03/18/2022 03:21 PM - It Cannot Be Edited

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: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
87307 Personal Accommodations and Services. (e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents .... This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure the pool in the backyard was lockable, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/19/2022
Plan of Correction
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Licensee stated they will obtain and install a lock on the backyard pool and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/18/2022 03:21 PM - It Cannot Be Edited

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: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
87307 Personal Accommodations and Services. (d) The following space and safety provisions shall apply to all facilities: (7) Fireplaces and open-faced heaters shall be adequately screened. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure the fireplace in the living room had a screen, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
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Licensee stated they will obtain a screen for the fireplace and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3