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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003937
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:09:13 AM

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:LOS TIEMPOS SENIOR LIVINGFACILITY NUMBER:
306003937
ADMINISTRATOR:ROSA FIGUEROAFACILITY TYPE:
740
ADDRESS:17935 LOS TIEMPOS STREETTELEPHONE:
(714) 964-6310
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rosa Figueroa, AdministratorTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by caregiver and granted entry. LPA advised caregiver the reason for the visit. LPA spoke to Administrator by telephone and explained the nature of the visit. Administrator arrived shortly after.

Upon entry LPA was screen per covid guidelines, LPA began the tour of the facility. The facility currently has 6 residents in care. LPA observed 1 resident in dining room doing activities, 2 residents in living room, and 3 residents in their bedrooms. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the visitors, staff, and resident. LPA observed handwashing guidelines posted in all bathrooms of facility. LPA observed facility has covid precautionary posting throughout the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of residents in care. LPA observed ample of emergency food and water as well as first aid kits in the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA observed caregivers cleaning and sanitizing facility. LPA toured the outside and observed 2 shaded outside space for resident, area is used for outdoor visitation as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility has 2 private bedrooms, 2 shared bedrooms, and 1 staff bedroom.

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.

An exit interview was conducted with Administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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