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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003937
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:04:32 PM


Document Has Been Signed on 03/12/2024 05:04 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: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:
03/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Rosa Figueroa, Licensee/AdministratorTIME COMPLETED:
05:05 PM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced case management- Health and safety check visit for the purpose to conduct a quarterly visit as agreed during Informal Meeting held on 1/31/2024. Additional visits will be conducted for the period of one year to expire on 1/31/2025. LPA Quiroz was greeted by Caregiver and met with Licensee/Administrator (L/AD) Rosa Figueroa and discussed purpose of today's visit.
During Informal Meeting held on 1/31/2024, the Licensee agreed to prepare and submit quarterly profit and loss statement with supporting documents such as monthly utility bills, lease payments and loan agreements to department audit section.First quarterly documents are to be submitted by end of first quarter 4/30/2024. During today's visit, Licensee Rosa Figueroa indicated to be working on gathering the profit and loss receipts to be able to submit them to department audit by 4/30/24.
LPA Quiroz along with (L/AD) Rosa Figueroa conducted a tour of the interior and exterior portions of the facility. During today's facility inspection, LPA Quiroz observed 6 (six) residents in care, of which (2) two residents are receiving hospice services. LPA observed an ample supply of perishables and non perishables as well as adequate emergency water supply. All utilities in service during today's visit. The sharps and medications were observed to locked and secured. The Facility appears clean and sanitary and of an appropriate temperature. LPA Quiroz observed 2 caregivers working during today's visit.

LPA did not observe immediate threat on the health and safety to residents in care.

No citation issued during today's visit.

LPA Quiroz conducted an exit interview with (L/AD). A copy of this report was provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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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