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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003416
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:18:27 PM


Document Has Been Signed on 06/09/2022 01:18 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: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: 2DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Elvie HawkTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced annual inspection focusing primarily on the Infection Control. LPA was greeted and granted entry by Administrator (Admin) Elvie Hawk. LPA stated the purpose of the visit and entered the facility after completing the Coronavirus 2019 (COVID-19) screening procedure. Upon entry, LPA observed the screening station with hand sanitizer on the table. The required COVID-19 precautionary signs were posted on the front door and throughout the facility. The Administrator's Certificate for Elvie Hawk expires on 2/13/2023.

Around 12:00 pm, LPA and Admin toured the interior and exterior portions of the facility. The facility is a single level structure and licensed for six non-ambulatory; and has a hospice waiver for four residents. As of today, facility had a total of two residents in hospice care. The two residents were sleeping in the shared bedroom and care was being provided by Caregiver Teresa Nunez. Facility appeared clean and sanitary in all observed areas. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide tested operational. Bathrooms observed to be in good repair; and provided with a grab bar and a non-skid floor mat. Facility had the required hand washing signs posted in all the bathrooms. Hot water measured at 105.0 degrees in Bathrooms #1 to #4. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. The fire extinguishers were mounted and charged in the kitchen. For the exterior portion, the facility had a gazebo and a patio with ample seating under a lattice, and grounds were free of tripping hazards. The side gates were self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had sufficient emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPE supplies stored in the closet.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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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: CAPSTONE GUEST HOME II
FACILITY NUMBER: 306003416
VISIT DATE: 06/09/2022
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LPA 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 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. Facility provides a smart phone for the residents to keep in contact with their families.

LPA Cho reviewed the COVID 19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the correction. An exit interview was conducted with Administrator Elvie Hawk, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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