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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003780
Report Date: 10/21/2021
Date Signed: 10/21/2021 02:01:32 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:FOUNTAIN VALLEY SENIOR CAREFACILITY NUMBER:
306003780
ADMINISTRATOR:NICOLETA ALINA MOGOJANFACILITY TYPE:
740
ADDRESS:9479 ELLIS AVENUETELEPHONE:
(714) 964-2529
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Nicoleta Alina Mogojan, Licensee/Administrator and Diana Igntencu, AdministratorTIME COMPLETED:
02:10 PM
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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Licensee/Administrator Nicoleta Mogojan and explained the nature of the visit. Facility is licensed to provide service to six (6) Non Ambulatory residents and has a hospice waiver for (2) two residents.

On or about 12:41pm, LPA Quiroz along with Licensee/Administrator Mogojan toured the inside and outside of the facility. There are (6) six residents in care and there are no active COVID-19 cases. LPA Quiroz observed one resident in living room area watching television and visiting with their family, one resident walking around facility and four residents in their bedrooms resting. All residents appeared to be clean and well taken care of.

During today's visit, LPA Quiroz observed staff and visitors wearing masks due to COVID-19 precautionary measures.

On or about 1:11pm, LPA Quiroz reviewed 6 of 6 resident records.

LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is screening visitors upon entrance, and taking temperatures of residents daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating areas for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan dated 4/01/2021 and LPA Quiroz approved the plan on today’s visit.

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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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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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: FOUNTAIN VALLEY SENIOR CARE
FACILITY NUMBER: 306003780
VISIT DATE: 10/21/2021
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Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Licensee/Administrator Mogojan, and a copy of this report was provided to Licensee/Administrator Mogojan at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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