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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004275
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:31:16 PM


Document Has Been Signed on 05/29/2024 04:31 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:CHEERFUL HEART HOME VFACILITY NUMBER:
306004275
ADMINISTRATOR:ANA SANDRUFACILITY TYPE:
740
ADDRESS:10722 ALBANY CIRCLETELEPHONE:
(714) 726-6525
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:6CENSUS: 6DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Ana SandruTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Michael Tea and Licensing Program Manager (LPM) Alisa Ortiz conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 1:30 PM, LPA and LPM were greeted and granted entry into the facility by caregiver, Daniela Rasadea and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are six residents, of which three are on hospice during today's visit. The Administrator, Ana Sandru arrived shortly after to assist during the visit.

At 1:32 PM, LPA Tea reviewed six resident files and two staff files. LPA Tea, LPM Ortiz along with the Administrator toured the facility at 2:16 PM. LPA and LPM toured the physical plant, checked food service, and the first aid kit. The home consists of 6 resident bedrooms, 1 staff bedroom, 3 and half bathrooms, living room, dining room, and kitchen. At 2:17 PM LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 112.1 F degrees and 113.3 degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. There are cameras placed in the common areas of the facility without audio for the safety of residents in care. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA and LPM observed secured medications in a cabinet. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating and the exit gate is self latching and operational. LPA observed emergency food and water supply in the garage. Facility provides activities in the form of outdoor activities such as going out for walks and doing exercises.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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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: CHEERFUL HEART HOME V
FACILITY NUMBER: 306004275
VISIT DATE: 05/29/2024
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At 2:38 PM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

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

This report was reviewed with care giver, Daniela Rasadea and a copy of this report LIC809, 809-C, LIC858, LIC859, LIC9102 was read and provided through email to the facility
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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