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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003416
Report Date: 07/06/2021
Date Signed: 07/06/2021 03:58:27 PM

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:CAPSTONE GUEST HOME IIFACILITY NUMBER:
306003416
ADMINISTRATOR:ELVIE HAWKFACILITY TYPE:
740
ADDRESS:17841 COLLINS AVENUETELEPHONE:
(714) 997-1953
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:6CENSUS: 3DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Elvie HawkTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Elvie Hawk and explained the reason for the visit.

At 11:20 AM, LPA toured the facility with Administrator Hawk. Facility has 3 residents under hospice care during today's visit. LPA observed residents relaxing in their rooms. All residents appeared well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Hand washing signs are posted throughout the facility. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily. Facility has covid precaution postings as well as all required department postings. Administrator Hawk has an administrator certificate expiring on 02/13/2023. Facility has completed the mitigation plan. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed ample shaded outside visitation areas. LPA observed a back house where staff resides. There is a fenced pool in the backyard. LPA observed the locked medication storage area as well as a locked closet containing toxins. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files which contained all required documentation including emergency information.

LPA consulted with Administrator regarding the importance of ensuring hand washing signage is posted in the restrooms as well as ensuring temperatures taken are documented daily.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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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