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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003421
Report Date: 10/26/2021
Date Signed: 10/28/2021 11:31:03 AM

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:SOUTH HOME CAREFACILITY NUMBER:
306003421
ADMINISTRATOR:ADELA ALBUFACILITY TYPE:
740
ADDRESS:2779 E. DIANA AVENUETELEPHONE:
(714) 630-5744
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Adela AlbuTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez met with Staff Glenda Awit and reason for visit was explained. Staff Awit confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility and asked to use a hand sanitizer/hand wash. Administrator Adela Albu arrived shortly after.

LPA observed the required Department posting on COVID-19 precautions at entrance of facility. There is a sign-in procedure in place and hand sanitizer for use. LPA observed that all staff were wearing face masks. The facility has an approved Mitigation Plan on file with CCLD.
There were 6 residents present during this visit, 1 receiving Hospice Services. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA toured all resident rooms, all rooms were within regulations. Residents appeared and stated they were very content with the staff and the facility. All restrooms observed contained soap/toilet paper/paper towels and had the proper hand washing signs posted. Facility has operating smoke and carbon monoxide detectors. Facility has Fire Extinguisher which was charged. LPA observed a copy of Administrators Certificate which expires on 11/20/2021. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted, and a secured location for resident's medication and files. Facility has 30 days supply of medications for the residents. Residents emergency contact information and Physicians reports are current. LPA reviewed 2 resident files.

Based on observations made during today’s inspection, no deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with Administrator and a copy will be emailed.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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