306004058-5-17-2022-22-AS-KSGH-CEHTWL-20220517150544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004058
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:05:53 PM

Document Has Been Signed on 05/17/2022 03:05 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:	INFINITY HOME CARE		FACILITY NUMBER:	306004058
ADMINISTRATOR:	DINA LUCACIU		FACILITY TYPE:	740
ADDRESS:	26051 CAMINO ADELANTO		TELEPHONE:	(949) 859-6019
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Monina De La Cruz, caregiver Roberto De La Cruz, caregiver Dina Lucaciu, administrator		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregivers Monina and Roberto De La Cruz after explaining the purpose of the visit. Administrator Dina Lucaciu was notified and arrived later to assist with the visit. At approximately 1:45pm, LPA accompanied by Roberto De La Cruz toured the inside and outside of the facility. There are currently five (5) residents in care, one (1) of which is receiving hospice care. Residents are observed relaxing in their respective individual bedrooms and all appear clean and well taken care of. The bedrooms include all necessary components. The bathrooms are equipped with grab bars and slip mats. Hand washing signs are being displayed. Facility appears to be clean, sanitary and free of odors in all areas inspected. The smoke and carbon monoxide detectors present are observed to be functional. The fire extinguishers are charged and have been verified in March 2022. Sharp instruments are stored in a kitchen cabinet with a magnetic lock, as are cleaning supplies. Additional cleaning supplies are secured under lock in the attached garage. LPA observed the facility has COVID-19 Precautions posters and required department postings. Facility has an adequate supply of PPE. LIC808 Mitigation Plan has been submitted. Staff present is adequately associated in Guardian. Lysol and glass cleaning solution are observed to be stored under the sink in one of the resident's attached bathroom. CONTINUED IN FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: INFINITY HOME CARE	FACILITY NUMBER: 306004058
	VISIT DATE: 05/17/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

CONTINUED FROM FORM LIC809

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility and observed it to be free of obstructions. The perimeter gates are self-latching and can easily be opened in an evacuation. No bodies of water are observed on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is issued in regard to the storage of cleaning products. This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3