306004275-4-15-2022-22-AS-ETAA-CDHLNU-20220415085455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004275
Report Date: 04/14/2022
Date Signed: 04/15/2022 08:55:00 AM

Document Has Been Signed on 04/15/2022 08:55 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:	CHEERFUL HEART HOME V		FACILITY NUMBER:	306004275
ADMINISTRATOR:	ANA SANDRU		FACILITY TYPE:	740
ADDRESS:	10722 ALBANY CIRCLE		TELEPHONE:	(714) 726-6525
CITY:	VILLA PARK	STATE: CA	ZIP CODE:	92861
CAPACITY:	6	CENSUS: 6	DATE:	04/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Daniela Rasadea, Ana Sandru		TIME COMPLETED:	12:00 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 Analysts (LPAs) Edward Tapia and Celine DePerio made an unannounced required annual inspection in this facility. LPAs met with staff Daniela Rasadea and stated the purpose of this visit. AD Ana Sandru arrived during the visit at 9:25 AM and provided assistance. The facility is a single level structure and licensed for of which 6 may be non-ambulatory. This facility is a Residential Care For the Elderly. About 9:15 AM, LPAs Tapia and DePerio were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPAs observed five clients in care and three staff members on the floor. LPAs toured the interior and exterior portions of the facility. There were five private client's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 110.4 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and hot water was measured at 105 degrees Fahrenheit. Bathroom (3) was observed to be in good repair and provided with grab bars and hot water was measured at 110.3 degrees Fahrenheit. Bathroom (4) was observed to be in good repair and provided with grab bars and hot water was measured at 106.8 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Garage was kept locked and was used as storage for emergency food, cleaning supplies and resident supplies. LPAs Tapia and DePerio reviewed the COVID 19 mitigation plan of the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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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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: CHEERFUL HEART HOME V	FACILITY NUMBER: 306004275
	VISIT DATE: 04/14/2022

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LPAs discussed Assembly Bill 665 that requires a licensee of any adult 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.

For this visit, no deficiency was noted in areas observed. No citation was issued.

LPAs Tapia and DePerio conducted an exit interview with AD Ana Sandru ; and copy of this report was left in the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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