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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003841
Report Date: 02/15/2022
Date Signed: 02/15/2022 12:14:52 PM


Document Has Been Signed on 02/15/2022 12:14 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:A PERICLES ELDERLY CARE HOMEFACILITY NUMBER:
306003841
ADMINISTRATOR:LUIS GAITANFACILITY TYPE:
740
ADDRESS:25822 PERICLESTELEPHONE:
(949) 859-2811
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Administrator Luis Gaitan TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this ffacility. LPA met with Administrator (AD) Luis Gaitan stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory and with hospice waiver for 4. For this visit there were four residents under hospice care.

About 11:30 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA toured the interior and exterior portions of the facility. LPA observed five residents in care and two staff members on the floor. There were five private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 110 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair, and grounds were free of tripping hazards. Side exit door was self-latching and self-closing. LPA Marin reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA advised AD to use office general email to send all reports: CCLASCPOrangeCountyRO@dss.ca.gov

LPA Marin conducted an exit interview with AD Gaitan; and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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