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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004060
Report Date: 07/27/2021
Date Signed: 07/27/2021 11:06:48 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:COYOTE HILLS RESIDENTIAL CAREFACILITY NUMBER:
306004060
ADMINISTRATOR:MIKE SFERDIANFACILITY TYPE:
740
ADDRESS:8271 COUNTRY CLUB DRIVETELEPHONE:
(714) 690-8000
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: 5DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Adela Pletez TIME COMPLETED:
11:20 AM
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20Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door and granted entry. LPA advised caregiver the reason for the visit.

LPA began the tour of the facility. The facility currently has 5 residents in care. LPA observed 2 residents in living room. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the check in station in the entry of the facility. Facility keeps documentation in regard to covid for all the visitors, staff, and residents. At 10:21am LPA tested the hot water temperature in bathrooms which are used by the residents. The hot water temperature was measured at 113 Fahrenheit degrees. LPA observed facility has covid precautionary postings through out the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of residents in care. LPA observed ample supply of food and water was well. LPA observes the facility has PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA toured the outside and observed two shaded space for residents, area is also used for outdoor visitation as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are single occupancy, all bedrooms are private.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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