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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003775
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:27:32 PM


Document Has Been Signed on 07/21/2022 03:27 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HEART TO HEART CARE HOME FOR ELDERLYFACILITY NUMBER:
306003775
ADMINISTRATOR:IMELDA CANLASFACILITY TYPE:
740
ADDRESS:3101 JEFFERSON AVENUETELEPHONE:
(714) 617-4708
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Angelien Delacruz, Elaine PamintuanTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Heart to Heart Home for Elderly. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on the Infection Control. At 2:11 pm, LPA Cho was allowed entry into the facility and met with Caregiver (CG) Elaine Pamintuan after completing the Coronavirus 2019 (COVID-19) screening procedure. House Manager (HM) Angeline Delacruz was also present. CG Pamintuan contacted Administrator (Admin) Imelda Canlas via telephone. Admin authorized a verbal consent for HM Delacruz to accompany the tour and sign the report. As of today, there are no active COVID-19 cases in the facility. Facility screens temperature for all visitors, and LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The facility is licensed for six non-ambulatory residents. The facility also has a Hospice Waiver for four residents. There are currently six residents living in the facility and one resident in hospice care. The Administrator's Certificate for Imelda Canlas expires on 07/22/2023.

Around 2:36 pm, LPA Cho conducted a tour of the physical plant along with HM Delacruz and CG Pamintuan. The single story home consists of five resident bedrooms and two resident bathrooms. There is a private staff bedroom. The facility also has a living room, dining area, kitchen, and an attached two car garage. The six residents in the facility appeared well-groomed and well cared-for. LPA Cho observed the Complaint Poster in the correct sizing. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. The required hand washing signs were observed in the bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 106.1 degrees Fahrenheit in Bathroom #1 and 108.8 degrees Fahrenheit in Bathroom #2.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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: HEART TO HEART CARE HOME FOR ELDERLY
FACILITY NUMBER: 306003775
VISIT DATE: 07/21/2022
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LPA Cho inspected the kitchen along with HM and CG. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested along with HM and CG and were found to be operational. Medications, toxins, and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho toured the outside grounds with HM. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the side gates were self-closing and self-latching. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply stored in the garage. The First Aid Kit had all the required components, and the facility had sufficient PPEs.


LPA Cho reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. A smart phone is available upon request.

LPA Cho reviewed the approved 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 House Manager Angeline Delacruz and Caregiver Elaine Pamintuan, 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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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