<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004336
Report Date: 07/12/2021
Date Signed: 07/12/2021 02:08:53 PM

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:NANA'S GARDEN 2FACILITY NUMBER:
306004336
ADMINISTRATOR:BRIGITTE FISKFACILITY TYPE:
740
ADDRESS:25312 ERICSON WAYTELEPHONE:
(949) 916-2928
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 2DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Bridgitte FiskTIME COMPLETED:
02:20 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) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by caregiver and granted entry. Administrator arrived shortly after and met with LPA. LPA explained the nature of today’s visit.

LPA accompanied by Administrator began the tour of the facility. The facility currently has 2 residents in care. LPA observed 1 resident in dinning room and 1 resident in bedroom taking a nap. Both residents appeared happy and well taken care of. Facility appears clean and sanitary in all areas inspected. Facility staff screens all visitors and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the staff, visitors, and residents. At 1:20pm LPA tested the hot water temperature in bathrooms which are used by the residents. The hot water temperature was measured at 118.6 Fahrenheit degrees. LPA observed facility has covid precautionary postings though out the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of all residents in care. LPA observed ample of emergency food and water as well as first aid kits in the facility. Facility has an ample supply of 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 a shaded outside space for resident in front and back area of the facility, area is 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 has 5 bedrooms with only one shared room being occupied.

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 Administrator 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: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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 1