306004376-1-17-2025-22-AS-BLOZ-DCZPX9-20250117104158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004376
Report Date: 01/17/2025
Date Signed: 01/17/2025 10:42:06 AM

Document Has Been Signed on 01/17/2025 10:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IRVINE CARE HOME		FACILITY NUMBER:	306004376
ADMINISTRATOR/ DIRECTOR:	CRISTINA EVANGELISTA		FACILITY TYPE:	740
ADDRESS:	41 BETHANY		TELEPHONE:	(949) 861-3178
CITY:	IRVINE	STATE: CA	ZIP CODE:	92603
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:05 AM
MET WITH:	Caregiver Milani Villasis		TIME VISIT/ INSPECTION COMPLETED:	10:55 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) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiver staff after explaining the purpose for the visit. Administrator (AD) Cristina Evangelista was notified via telephone and could not arrive to assist due to being at a doctor's appointment. LPA observed that Cristina Evangelista has a valid Administrator certificate which expires on May 24, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for two. The facility is a single-story home with four private resident bedrooms, two staff bedrooms, three shared resident bathrooms, a living room, a dining room, a kitchen, a courtyard, and an attached two car garage. LPA accompanied by caregiver staff conducted a tour of the physical plant. On today's visit, LPA observed four residents in care, one of which is received hospice care, and three caregiver staff present. LPA observed residents eating their breakfast in the dining room as well as eating in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall in the dining room measured 11 by 17 inches measured. LPA inspected the four resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the three shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 109.5 and 118.4 degrees Fahrenheit. LPA observed the two staff bedrooms are kept locked and inaccessible to residents. LPA observed the kitchen has a two-day perishable and seven-day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The four burner gas stove lights unassisted. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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: IRVINE CARE HOME	FACILITY NUMBER: 306004376
	VISIT DATE: 01/17/2025

NARRATIVE

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LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies are stored in a locked kitchen cabinet under the sink.Fire extinguishers are located in the dining room and garage. Fire extinguishers were observed to be charged and purchased on January 10, 2025. LPA tested the wired smoke detector/carbon monoxide detector which tested operational. LPA observed the facility conducted their last emergency disaster drill on January 4, 2025. The centrally stored medication is kept in a locked storage cabinet in the kitchen. LPA observed the First Aid kit has all the required components. The door leading to the attached two car garage is kept locked and inaccessible to resident. The garage is used for storage and laundry. LPA observed chemicals and toxins stored in the garage. LPA observed the facility has an emergency food and water supply stored in the garage.

LPA and caregiver staff conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the southside of the facility is self-latching and can be opened in an evacuation. There is a fountain located in the courtyard. The fountain is not in operation and is adequately fenced for resident safety.

LPA reviewed the four resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed four residents’ medication and medication records. LPA reviewed the Personal and Incidental expense monies (P&I) records for four out of four residents. LPA reviewed six staff files. All staff are background cleared and associated to the facility.

Based on today's observations, there are no deficiencies being cited per Title 22 of the California Code of Regulations. AD advised LPA via telephone that a caregiver staff had permission to sign the report. An exit interview was conducted with caregiver staff and a copy of the report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

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