306003443-10-25-2022-22-AS-JHAY-CKJQ5F-20221025115154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003443
Report Date: 10/25/2022
Date Signed: 10/25/2022 11:52:12 AM

Document Has Been Signed on 10/25/2022 11:52 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:	ACTIVE SENIOR HOME CARE		FACILITY NUMBER:	306003443
ADMINISTRATOR:	BINTINTAN, AURICA		FACILITY TYPE:	740
ADDRESS:	26771 VIA VICTORIA		TELEPHONE:	(949) 380-1143
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	10/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Aurica Bintintan		TIME COMPLETED:	11:55 AM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Aurica Bintintan was present for the visit. AD Bintintan has a current administrators certificate that expires 03/25/24.

At 10:05 AM LPA Haley and AD Bintintan began the inspection at the entrance of the facility. A screening station with hand sanitizer and mask was observed outside the front door. A temperature thermometer and log book was inside the facility right by the front door.There were six residents present during the visit.

Resident bedrooms had all necessary requirements: night stand, chair, lamp and storage space. In resident bathrooms, hot water temperature was measured at 107.9 degrees Fahrenheit in bathroom #1 and bathroom #2. In bathroom #3 hot water measured at 109.7 degrees Fahrenheit. In bathroom #4 and #5 hot water measured at 105.9 degrees Fahrenheit. There are two hallway closets near the living room. Closet one is used to store miscellaneous items, and in closet #2 across the hall, is used to store resident files, staff files, and medication records.

LPA Haley observed a locked medication cabinet in the kitchen. There was a first aid kit in the medication cabinet. LPA observed a fully charged fire extinguisher mounted on the wall near the medication cabinet. Knives and sharp objects locked in a drawer near to the sink. All hazardous cleaning chemicals were locked in a drawer near the sink.

In the garage, plenty of supplies were observed. LPA observed extra mattresses and bed frames. There's a washer and dryer located in the garage. On the shelves in the middle of the garage LPA observed plenty of additional cleaning supplies. There is an emergency supply of PPE in the garage: N95 mask, face shields, gowns, gloves, wipes, and hand sanitizer. In the cabinets above the shelves there is a supply of non-perishable food items. Two additional refrigerator's stocked with plenty of perishable food items was observed.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

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: ACTIVE SENIOR HOME CARE	FACILITY NUMBER: 306003443
	VISIT DATE: 10/25/2022

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The backyard had clear walkways, free of tripping hazards. Both side exit gates were self closing and self latching. LPA Haley observed a shaded patio area with tables, chairs and a ceiling fan. Two locked storage sheds were observed in the backyard. One shed was used for the storage of facility supplies like adult diapers, emergency blankets and clothing and the second shed was used to store facility equipment like fans, and bed frames.

LPA of Haley observed items in the back yard that are no longer being used and need to be disposed of. The clutter observed consist of various items: wood, metal poles, and buckets to name a few of the items observed. The clutter is off to the side and does not obstruct any walkways or evacuation routes. LPA Haley advised Administrator Bintintan the importance of keeping the facility free and clear of clutter and debris at all times. The facility has a surplus of supplies and other items needed to keep the facility running and keeping everything neat and organized was discussed. AD Bintintan understood, agreed and stated she will start working on organizing some of the areas in the facility that need it.

No bodies of water were observed during today's visit. All smoke detectors were tested and are operational.

No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report was provided to Administrator Bintintan.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC809 (FAS) - (06/04)

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