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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003549
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:25:50 PM


Document Has Been Signed on 11/08/2022 02:25 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAMINO HILLS OF SAN CLEMENTEFACILITY NUMBER:
306003549
ADMINISTRATOR:MARIA LAFIGUERAFACILITY TYPE:
740
ADDRESS:2924 ARROYOTELEPHONE:
(949) 369-9487
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
02:40 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Elizabeth Olvera and explained the reason for the visit. Administrators (ADs) Cecelia Domingo and Mercedita B. Lafiguera-Ang arrived during the visit. Licensee Lafiguera-Ang has an administrator certificate expiring on 11/25/2022.

At 1:09 PM, LPAs toured the facility with Administrator Lafiguera-Ang . Facility has six Residents in care during today's visit, with two on hospice care. LPAs observed Residents relaxing in the facility. All Residents appeared well taken care of. Facility appears clean and sanitary. All Resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Hand washing signs are posted in the restrooms. LPAs observed the screening station in the entrance of the facility. Facility screens all visitors to the facility and documents. Facility has covid precaution postings as well as all required department postings. Facility takes Resident and Staff temperatures daily and documents. LPAs toured the kitchen and observed ample food supply. Facility has completed the mitigation plan and plan has been approved. LPAs observed emergency food and water as well as the first aid kit which contained all required items. Smoke detectors were hardwire and tested operational during today's visit. Fire extinguishers were mounted and charged. LPAs toured the outside grounds and observed the outside visitation area. Residents participate in activities such as exercise, games and dog therapy. LPAs observed the locked medication storage area. 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. LPAs reviewed select Resident files which contained all required documentation including emergency information.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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