306003937-7-8-2022-22-AS-JTIE-CG5PJQ-20220708112156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003937
Report Date: 07/08/2022
Date Signed: 07/08/2022 11:22:09 AM

Document Has Been Signed on 07/08/2022 11:22 AM - 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:	LOS TIEMPOS SENIOR LIVING		FACILITY NUMBER:	306003937
ADMINISTRATOR:	ROSA FIGUEROA		FACILITY TYPE:	740
ADDRESS:	17935 LOS TIEMPOS STREET		TELEPHONE:	(714) 964-6310
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	07/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Administrator, Rosa Figueroa		TIME COMPLETED:	11:40 AM

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On today's date, Licensing Program Analysts (LPAs) LPA Rosie Quiroz and Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual inspection. LPAs were greeted and granted entry into the facility by Caregiver Karina Lomelit. LPAs explained the nature of the visit. (L/AD) Rosa Figueroa arrived shortly after. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 6 Non-Ambulatory residents, and has a Hospice Waiver for 4 residents. Facility currently providing services to 1 resident on hospice. (L/AD) Rosa Figueroa has a current Administrator certificate with expiration date of September 8, 2023.

On or about 8:52am, LPA Rosie Quiroz along with (L/AD) Figueroa began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed one of six residents in their bedroom eating breakfast, and five of six residents observed to be eating breakfast in dining-room area supervised by caregivers. LPA Quiroz interacted and interviewed with resident's during today's visit. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 77 degrees Fahrenheit.

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 105.8- 107.2 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and kitchen area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for residents and visitor's enjoyment in backyard area.

CONTINUED ON 809C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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: LOS TIEMPOS SENIOR LIVING	FACILITY NUMBER: 306003937
	VISIT DATE: 07/08/2022

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The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on July 6, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated July 6, 2021.

LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and some of the residents and staff have had their first and second Booster. Facility indicated to be recording resident's temperatures daily.

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.

During today's visit, LPAs provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

This report was reviewed with (L/AD) Rosa Figueroa, and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

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