306003618-5-9-2024-22-AS-RMAZ-D54SPE-20240509140301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003618
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:03:06 PM

Document Has Been Signed on 05/09/2024 02:03 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	NEIGHBORHOOD SUITES - COSTEAU		FACILITY NUMBER:	306003618
ADMINISTRATOR:	OFELIA ANGELES		FACILITY TYPE:	740
ADDRESS:	25005 COSTEAU STREET		TELEPHONE:	(949) 290-6907
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 4	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Ignatius Rusli		TIME COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ruth Martinez and Faith La is conducting this unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and was greeted and granted entry by caregivers Ang Siong and Ronald Tumbio and LPAs explained the nature of the visit. There are four residents at the facility and there are two residents receiving hospice services currently. Ignatius Rusli, Administrator arrived shortly after and met with LPAs. Four residents reside at this facility. There were four residents at the time of the visit. LPAs accompanied with Administrator Ignatius Rusli began the tour of the inside and outside of the facility. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage a spare refrigerator and pantry in the garage. The facility is maintained at a comfortable temperature. LPAs inspected that medication is centrally stored in a safe locked storage cabinet located in kitchen. LPAs reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPAs inspected the bathroom and LPAs measured the hot water temperature which measured 112.8 Fahrenheit degrees. All two bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage cabinet in the garage. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors/ carbon monoxide were tested and found to be operational. Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEIGHBORHOOD SUITES - COSTEAU	FACILITY NUMBER: 306003618
	VISIT DATE: 05/09/2024

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LPAs toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed the pool gate has an entry door which opens away from the pool. The fence has a lock that requires a key at the gate door for inaccessibility. LPAs measured the pool fence which measured 5ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPAs observed a fire extinguisher with service date of January 02, 2024, in kitchen. Fire drills are conducted every three months. LPAs began review of records. LPAs reviewed two resident records. All the required documentation was present and current in the residents’ files reviewed. LPAs reviewed two employee records. All employees present a criminal record clearance and are associated to the facility. LPAs observed records reviewed have a current First Aid certificate.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. LPAs are issuing an LIC 9102 (Technical Advisory) in lieu of a citation.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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