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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003706
Report Date: 05/17/2022
Date Signed: 05/17/2022 10:49:16 AM


Document Has Been Signed on 05/17/2022 10:49 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:GLENWOOD CAREFACILITY NUMBER:
306003706
ADMINISTRATOR:DORA VILLAGRANFACILITY TYPE:
740
ADDRESS:2001 EAST GLENWOODTELEPHONE:
(714) 626-0796
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 6DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Dora VillagranTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct the required annual (mitigation) inspection. LPA was greeted and granted entry by Administrator (Admin) Dora Villagran after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA observed that facility has a COVID-19 screening procedure that is completed per visitor with temperature check. The Administrator's Certificate for Dora Villagran is expiring on 12/18/22 and 5/25/22 for Edwin Villagran. LPA stated the purpose of the visit and began the tour of the facility with the Admin.

The facility is a single level structure and licensed for six non-ambulatory residents and has an approved waiver for six hospice residents. As of today, there are four residents in hospice care. LPA observed four staff on duty including the Admin, two residents resting in the living room watching television, and four residents resting in their respective bedrooms. LPA observed the required department postings at the front door and all around the facility as well as hand washing signs in the restroom. LPA observed the PUB475 See Something, Say Something in the size of 8.5" x14 in", and LPA requested an enlarged size of 20"x26." LPA observed all restrooms had ample soap/sanitizer, paper towels, and appeared clean. Bathrooms were provided with grab bars and a non-skid floor mat. Residents' bedrooms appeared clean and sanitary and had all required components. Smoke detectors, carbon monoxide, and auditory exit alarms were tested operational. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Sharp items, medications, and cleaning supplies were inaccessible to the residents in care. For the exterior portion, facility had patio furniture under ample shading. LPA observed the emergency disaster and evacuation plans. Facility does have back-up emergency food and water supply and has a 30 day supply of PPEs. The First Aid Kit met all the required elements. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA observed a tablet for resident use.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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: GLENWOOD CARE
FACILITY NUMBER: 306003706
VISIT DATE: 05/17/2022
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LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the correction. An exit interview was conducted with Administrator Dora VIllagran and Edwin Villagran , and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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