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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003527
Report Date: 06/28/2021
Date Signed: 06/28/2021 03:04:19 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:YORBA LINDA SENIOR CAREFACILITY NUMBER:
306003527
ADMINISTRATOR:CHRISTOPHER CURTISFACILITY TYPE:
740
ADDRESS:4451 ACORN COURTTELEPHONE:
(714) 993-0449
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 2DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Christopher CurtisTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to facility to conduct an Annual visit. Upon arrival LPA met with Staff Alfonso Amper. Administrator Christopher Curtis arrived a short time later.

During the visit LPA toured the facility inside and out with Alfonso Amper. LPA observed Covid signage at front entrance of facility as well as a sanitization station. Facility has required Department postings. LPA observed a copy of Administrator Certificate for Christopher Curtis that expires 3/7/22. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained ample supplies of hand sanitizer, soap, wipes, gloves and paper towels. LPA observed outside visitation area with ample shading. Residents were observed watching tv. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with Administrator regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff at all times. PIN 21-17.2 was also discussed.

No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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