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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003020
Report Date: 05/09/2022
Date Signed: 05/09/2022 10:22:59 AM


Document Has Been Signed on 05/09/2022 10:22 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:CAMINO HILLS CARE HOME 2FACILITY NUMBER:
306003020
ADMINISTRATOR:MARIA CECILIA DOMINGOFACILITY TYPE:
740
ADDRESS:2940 ARROYOTELEPHONE:
(949) 369-1609
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mercedita Lafiguera-AngTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Albert Marin and Celine De Perio made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Mercedita Lafiguera-Ang and stated the purpose of this visit.

This facility is a single level structure a and licensed for 6 non-ambulatory and with hospice for six. . For this visit, there were three residents under hospice care.

LPAs Marin and De Perio were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPAs toured the interior and exterior portions of the facility. There were six private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails and nonskid floor mats. Hot water was measured at 120 degrees Fahrenheit. Medications, cleaning supplies and sharp kitchen items were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day non- perishable food stock requirements. LPAs observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit door was self closing. LPAs reviewed the COVID 19 mitigation plan of the facility. LPAs discussed Assembly Bill 665 that requires a licensee of any adult or senior 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 an support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Administrator's certificate is valid until November 25, 2022.

No citation was issued for this visit..

LPAs Marin and De Perio conducted an exit interview with AD Figuera-Ang and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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