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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003780
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:40:18 PM

Document Has Been Signed on 10/28/2024 03:40 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:FOUNTAIN VALLEY SENIOR CAREFACILITY NUMBER:
306003780
ADMINISTRATOR/
DIRECTOR:		NICOLETA ALINA MOGOJANFACILITY TYPE:
740
ADDRESS:9479 ELLIS AVENUETELEPHONE:
(714) 964-2529
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:27 PM
MET WITH:Nicoleta MogojanTIME VISIT/
INSPECTION COMPLETED:
04:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Nicoleta Mogojan and explained the reason for the visit. The facility is a two story house with 10 bedrooms (8 bedrooms on the first floor, 6 are for residents, all are private), 10 bathrooms ( 8 bathrooms on the first floor, 7 are for residents), living room, dining room, kitchen and an attached 3 car garage. The second floor is inaccessible to residents. LPA and the Administrator toured the facility. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The 5 burner gas stove top lights unassisted. The fire extinguisher in the kitchen is fully charged. LPA toured the garage. LPA observed a 3 emergency food and water supply in the garage. LPA observed a bed set up in the garage. The Administrator verified a staff member has been sleeping in the garage. LPA observed the PUB 475 poster is posted in the hallway and is 8 1/2 by 11 inches in size. LPA observed all resident rooms have the required furnishings. LPA observed the fireplace in the living room is screened. All 7 resident bathrooms are clean and operational. Hot water measured 109.9 degrees Fahrenheit. LPA observed all resident rooms are clean and organized. All resident rooms had the required furnishings and linens. The smoke detectors/carbon monoxide detectors tested operational. There is no documentation that the facility conducted a recent fire drill in the last 3 months. LPA and the Administrator toured the backyard. LPA observed there is a hot tub in the backyard. The hot tub has a cover that is locked in place and inaccessible to residents. LPA observed a shaded seating area with a table and chairs for residents to sit outside. LPA reviewed 2 staff files, no discrepancies. Both staff members have the required training and are background cleared and associated to the facility. LPA reviewed 6 resident files and medications, no discrepancies observed. LPA consulted with the Administrator concerning reporting requirements and fire safety. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018
DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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Document Has Been Signed on 10/28/2024 03:40 PM - It Cannot Be Edited

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: FOUNTAIN VALLEY SENIOR CARE
FACILITY NUMBER: 306003780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed and the Administrator verified the garage is being used as a bedroom by staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee agrees to remove the bed from the garage and to stop using the garage as a bedroom for staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 03:40 PM - It Cannot Be Edited

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: FOUNTAIN VALLEY SENIOR CARE
FACILITY NUMBER: 306003780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, LPA reviewed facility documents and there is no record of an emergency drill being conducted in the last 3 months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee agrees to conduct an emergency disaster drill and to document the drill in writing. Licensee to forward proof to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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