306003780-9-8-2022-22-AS-RQUZ-CJ3SQF-20220908140440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003780
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:05:03 PM

Document Has Been Signed on 09/08/2022 02:05 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:	FOUNTAIN VALLEY SENIOR CARE		FACILITY NUMBER:	306003780
ADMINISTRATOR:	NICOLETA ALINA MOGOJAN		FACILITY TYPE:	740
ADDRESS:	9479 ELLIS AVENUE		TELEPHONE:	(714) 964-2529
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Diana Ignatencu, Caregiver/Designated of Facility Responsibility (DOFR)		TIME COMPLETED:	02:19 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- Infection Control visit. LPA Quiroz was greeted, and granted entry into the facility by Designated of Facility Responsibility (DOFR) Diana Ignatency and explained the nature of the visit. (DOFR) indicated Administrator Nicoleta Mogojan is currently out on vacation, scheduled to return next week. Diana Ignatrmcu identified self as Designated of Facility Responsibility. LIC 308 dated 9/20/2021 on file.

This facility is licensed to provide services to (6) six Non-Ambulatory Residents and has a hospice waiver for two (2) residents.

(AD) Nicoleta Mogojan has an Administrator Certificate with expiration date of 10/31/2023. (AD) Diana Ignatencu has an Administrator Certificate with expiration date of 11/11/2022.

On or about 1:40pm LPA Quiroz along (DOFR) Ignatencu with toured the inside and outside of facility. The staff working at facility on today's date were observed to be wearing face masks upon arrival to facility. There are six residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed three (3) residents in living room area watching television, (1) one resident visiting with Family, and (2) two residents resting in their bedrooms. Six of six residents appeared to be clean and well taken care of. 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 taking temperatures 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 shaded area with table and chairs for residents and visitors enjoyment. Facility has completed the LIC 808 Mitigation plan and infection control plan. CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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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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: 09/08/2022

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During today's inspection visit, LPA Quiroz reviewed six of six resident records. DOFR indicated "all residents and staff at facility are fully vaccinated for COVID-19 and have received 1 booster. Staff have 2 boosters."

During today's visit, water temperature was recorded to be within normal limits, indoor facility temperature was recorded to be 77 degrees Fahrenheit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

LPA Quiroz provided consultation on Infection control and Hospice Waiver increase request procedure.

This report was reviewed with (DOFR) Ignatencu and a copy of this report, LIC 811-Confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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