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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004058
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:22:59 PM

Document Has Been Signed on 08/09/2024 02:22 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:INFINITY HOME CAREFACILITY NUMBER:
306004058
ADMINISTRATOR/
DIRECTOR:		DINA LUCACIUFACILITY TYPE:
740
ADDRESS:26051 CAMINO ADELANTOTELEPHONE:
(949) 859-6019
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Care Giver Roberto De La Cruz

Administrator Dina Lucaciu		TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by care giver Roberto DeLa Cruz to whom LPA discussed the purpose of the visit.. LPA also discussed the purpose of the visit over the phone with Licensee/Administrator Dina Lucaciu.

According to the facility’s license, the facility has a maximum capacity of six (6) non-ambulatory clients of which 1 may be bedridden. Facility also has a hospice waiver for 4.

LPA, accompanied Care Giver Roberto DeLa Cruz, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Centrally stored medications were properly stored and locked in medication room. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

[Continued on 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: INFINITY HOME CARE
FACILITY NUMBER: 306004058
VISIT DATE: 08/09/2024
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[Continued form 809]

No pools or bodies of water on the premises. Per Care Giver Roberto DeLa Cruz, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. LPA interviewed staff members and Residents. LPA interviews did not raise any licensing concerns. Staff records review verified that all staff records are complete and compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. Administrator’s certification is current.



LPA Reviewed resident records and confirmed most required documents were on file. During the client file review it was discovered that 2 of 6 tuberculosis test results are missing from files. LPA issued a Technical Violation for missing documentation in the residents files. According to Licensee the documentation is present but they are unable to locate.

An exit interview was conducted with Licensee/ Administrator Dina Lucaciu over the phone and Care giver Roberto DeLa Cruz in person , to whom copies of this report, a copy of the LIC 9012, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

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SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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