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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004336
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:46:41 AM


Document Has Been Signed on 06/21/2022 11:46 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: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: 5DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Brigitte FiskTIME COMPLETED:
11:55 AM
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) Jessica Cho conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 11:08 am, LPA was greeted and granted entry by Caregiver Lawrence Balangue after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA was then greeted by Administrator (Admin) Brigitte Fisk who appeared from the dining room. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperature for all staff and visitors on a sign in sheet. Upon entry, LPA observed the required COVID-19 precautionary signs posted on the main entrance door and around the facility. Tthe PUB475 See Something, Say Something poster was observed by the entryway in the size of 8.5"x11." The Administrator's Certificate for Brigitte Fisk expires on 9/27/2023.

Around 10:30 am, LPA toured the interior and exterior portions of the facility with Admin Fisk, Caregiver Balangue, and Caregiver Pingkan Mamanua. The facility is a single level structure and licensed for six non-ambulatory residents; and has a hospice waiver for six. Currently, there a total of five residents in the facility of which three are in hospice care. Facility appeared clean and sanitary in all areas observed. All four bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxides and auditory exit alarms tested operational. The restrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water measured at 131.9 degrees Fahrenheit in Restroom #1 and 131.5 degrees Fahrenheit in Restroom #2 which was adjusted during the visit. LPA observed hand washing signs, paper towels, and hand soaps in the restrooms. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. Fire extinguisher was mounted and charged in the family room area. For the exterior portion, LPA observed patio furniture under ample shading, and the grounds were free of tripping hazards. The side gate was self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had back-up emergency food and water supply. The First Aid Kit had all the required components except the manual. The facility had sufficient PPEs and incontinence supplies stored in the garage.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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 6


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: NANA'S GARDEN 2
FACILITY NUMBER: 306004336
VISIT DATE: 06/21/2022
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
26
27
28
29
30
31
32
Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior 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. Residents have access to the tablet provided by the facility upon request.



LPA consulted the following: To enlarge the PUB475 See Something, Say Something poster, to purchase a current edition of the first aid manual, and to maintain the hot water temperature between 105 to 120 degrees Fahrenheit.

LPA reviewed the approved COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Brigitte Fisk, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6