306002942-7-21-2022-22-AS-ETAA-CGJP4V-20220721105946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002942
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:00:05 AM

Document Has Been Signed on 07/21/2022 11:00 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:	NIGUEL HILLS VILLA II		FACILITY NUMBER:	306002942
ADMINISTRATOR:	RHODORA GULLAND		FACILITY TYPE:	740
ADDRESS:	24965 VIA LARGA		TELEPHONE:	(949) 573-3203
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	6	CENSUS: 1	DATE:	07/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rhodora Gulland, Robert Guland		TIME COMPLETED:	11:10 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	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with Administrator Rhodora Gulland and staff Robert Gulland and stated the purpose of this visit. The facility is a single level structure and licensed for six non-ambulatory with a hospice waiver for two. This facility is a Residential Care Facility for the Elderly. LPA Tapia informed Administrator Rhodora “Icy” Gulland of the facility’s overdue annual fees and provided a copy of the Facility Transaction History including a PIN so fees can be paid online. Administrator made the payment and provided LPA with a copy of confirmation. At about 9:15 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 1 resident in care and one staff member on duty. LPA toured the interior and exterior portions of the facility. There were 3 resident rooms 2 of which were vacant. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide were tested to be operational. LPA noticed that auditory exit alarms were not operational. Administrator was made aware of this and will have them replaced. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 121.8 degrees Fahrenheit. LPA noticed there were toxins on the bathroom floor. Administrator removed them immediately. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was on observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Garage is kept locked and used for storage and with an emergency supplies. Laundry room was in good repair with cleaning supplies kept locked. Kitchen was in good repair with medications kept locked separately.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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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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: NIGUEL HILLS VILLA II	FACILITY NUMBER: 306002942
	VISIT DATE: 07/21/2022

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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Five advisories and a technical violation was issued today.

LPA Tapia conducted an exit interview with Administrator Rhodora “Icy” Gulland and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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