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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003955
Report Date: 08/10/2021
Date Signed: 08/10/2021 03:38:58 PM

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:ARBOR COVEFACILITY NUMBER:
306003955
ADMINISTRATOR:KATHLEEN TOOMEY SMITHFACILITY TYPE:
740
ADDRESS:25735 CERVANTES LANETELEPHONE:
(949) 830-0266
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
08/10/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Administrator Cynthia "Cindy" ShogaTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management and health and safety check. LPA met with Administrator (AD) Cynthia "Cindy" Shoga and stated the purpose of this visit.

About 1:10 PM, LPA Marin was granted entry in the facility after completing the Coronavirus 2019 (COVID 19) screening procedures. LPA toured the interior and exterior portions of the facility. LPA observed four residents in care and two staff members on the floor. LPA reviewed the criminal background clearances. There were six private rooms. Rooms were provided with provided with furniture in good repair, clean linens and adequate storage space; and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Fire extinguisher was mounted and charged. Kitchen appeared clean. Medications, cleaning supplies and sharp kitchen items were inaccessible to residents in care. For the exterior portion of the facility, there were patio furniture in good repair and grounds were free of tripping hazards.

AD Shoga discussed the overall status of the facility and the transition plan for change of ownership.

Due to time constraints, this visit will be completed at a later time.

For this visit , no citation was issued at this time.

LPA Marin conducted an exit interview with Administrator Cindy Shoga 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: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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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