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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004028
Report Date: 08/17/2022
Date Signed: 08/17/2022 11:16:13 AM


Document Has Been Signed on 08/17/2022 11:16 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:ARBOR VIEW IIFACILITY NUMBER:
306004028
ADMINISTRATOR:FISK, MARK & ERINFACILITY TYPE:
740
ADDRESS:25342 MAXIMUS STREETTELEPHONE:
(949) 295-9191
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Administrator Mark Fisk TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Mark Fisk and stated the purpose of this visit.

About 9:44 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPAs toured the interior and exterior portions of the facility. This facility is a single level structure and licensed for 6 non-ambulatory of which one may be bedridden and with hospice waiver for three. On this visit, there was one resident under hospice care. LPA observed six residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility with AD M. Fisk. There were one shared and four private resident's rooms, which were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails; and water fixtures were observed to be in good repair. Hot water was measured at 105 degrees Fahrenheit. Medications, and cleaning supplies were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day non perishable food stock requirements. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit door was self latching and self closing. LPA reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA also discussed the California Code of Regulations (CCR) Section 87470 Infection Control Requirements, and CCR Section 87608 Postural Supports. AD's certificate is valid until 01/26/2024. AD was informed to send all incident reports and general correspondence to CCLASCPOrangeCountyRO@dss.ca.gov

No citation was issued for this visit.

LPA Marin conducted an exit interview with AD M. Fisk and copy of this report, advisory notes, and CCR sections discussed
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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