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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004376
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:22:26 PM


Document Has Been Signed on 04/08/2022 03:22 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:IRVINE CARE HOMEFACILITY NUMBER:
306004376
ADMINISTRATOR:CRISTINA EVANGELISTAFACILITY TYPE:
740
ADDRESS:41 BETHANYTELEPHONE:
(949) 861-3178
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY:6CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Jose Villasis & Milani Villasis - Caregivers TIME COMPLETED:
10:26 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Jose Villasis and Milani Villasis and explained the reason for the visit.

At 9:10am, LPA toured the facility with Caregiver Milani . Facility is a 5 bedroom, 3 bathroom, single story home with an attached garage. Facility has 4 residents present during today's visit. LPA observed residents relaxing in their respective rooms. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility uses a handwritten sign in. Facility takes resident and staff temperatures daily and documents. Facility has COVID precaution postings. LPA observed locked medication drawer. Fire extinguisher is mounted and charged. LPA toured the outside grounds and observed outside shaded visitation area. LPA observed the activity room including exercise equipment and movies. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. LPA observed a 4 week supply of PPE. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files and all contained required documentation including updated emergency information.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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