306002969-8-22-2024-22-AS-KLYN-D8DR4L-20240822124142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002969
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:41:02 PM

Document Has Been Signed on 08/22/2024 03:41 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:	AVONDALE FAMILY CARE HOME II		FACILITY NUMBER:	306002969
ADMINISTRATOR:	MARIA TERESA NAVARRA		FACILITY TYPE:	740
ADDRESS:	3129 INCLINADO		TELEPHONE:	(949) 429-8190
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	6	CENSUS: 5	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Regina Basa and Tess Navarra		TIME COMPLETED:	01:05 PM

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) Kimberly Lyman conducted an unannounced visit to Avondale Family Care Home II. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which 4 may be bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 1 resident on hospice. Administrator Tess Navarra arrived during the visit. Administrator Tess Navarra has an administrator certificate valid until 04/14/2025. LPA Lyman along with Administrator Tess Navarra toured the facility at 10:00 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. Facility appears to be clean, safe, and sanitary. The home consists of four resident bedrooms, 2 common restrooms, resident restroom, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.9 and 110.6 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Auditory exit alarms were operational during today's visit. First aid kit had all the elements including thermometer, tweezers and scissors. LPA observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked and self latching. LPA observed a pool secured by a fence. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan and infection control and plans are thorough and complete. CONT ON LIC809-C DATED 08/22/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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: AVONDALE FAMILY CARE HOME II	FACILITY NUMBER: 306002969
	VISIT DATE: 08/22/2024

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

Facility provided documentation of last fire drill conducted in June 2024. Facility provides activities in the form of exercise, and games. LPA reviewed five resident files and two staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation as well as CPR training and criminal record clearance. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order and medications are audited weekly.

Based on the observations made during today's visit, NO citations are being issued. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2