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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003955
Report Date: 09/20/2021
Date Signed: 09/21/2021 08:14:29 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: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:
09/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator Cynthia ShogaTIME COMPLETED:
02:54 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to the facility to conduct a case management. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. LPA met with Administrator (AD) Cynthia "Cindy" Shoga, and stated the purpose of the visit.

For this visit, LPA toured the interior and exterior portions of the facility with AD Shoga. Facility is undergoing renovation and upgrades. LPA discussed the Provider Information Notice (PIN) 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID 19). LPA also discussed the COVID 19 mitigation plan of the facility; and best practices maintaining safe environment for residents while construction work is done in the facility.

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

LPA Marin conducted an exit interview with AD Shoga.

Due to technical issue encountered during the visit, this report was issued on September 21, 2021 after completing a teleconference with AD Shoga. LPA will send copy of this report via email, and AD agreed to acknowledge its receipt.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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