306004454-11-4-2021-22-AS-RQUZ-C8FP6S-20211104110248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004454
Report Date: 11/04/2021
Date Signed: 11/04/2021 11:02:52 AM

COMPREHENSIVE INSPECTION

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:	NS CARE		FACILITY NUMBER:	306004454
ADMINISTRATOR:	NOVAC SOFRONI		FACILITY TYPE:	740
ADDRESS:	10431 AVENIDA CINCO DE MAYO		TELEPHONE:	(714) 599-3531
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 5	DATE:	11/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Novac Sofrani, Administrator		TIME COMPLETED:	11:17 AM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted, and granted entry into the facility by Licensee/Administrator (L/AD) Novac Sofrani and explained the nature of the visit.

This facility is licensed to provide services to residents age range 60 and over, 6 (six) Non-Ambulatory Residents; of which 6 (six) may be bedridden and has a hospice waiver for two (2) residents. L/AD Novac Sofrani has an Administrator Certificate with expiration date of 6/26/2023.

On or about 9:14am LPA Quiroz along with L/AD Sofrani toured the inside and outside of facility. There are five (5) residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed three (3) residents in their bedroom eating breakfast and watching television, (1) one resident sleeping in his bedroom and (1) one resident in living-room area eating his breakfast and watching television. Five of five residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. L/AD Sofrani indicated facility is taking temperatures daily, but not documenting results. L/AD Sofrani indicated "We were documenting during the surge, but will start documenting temperature results again daily."

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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: NS CARE	FACILITY NUMBER: 306004454
	VISIT DATE: 11/04/2021

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Facility has completed the LIC 808 Mitigation plan dated 1/12/2021. LIC 808 was approved by LPA Quiroz during today's visit.

During today's inspection visit, L/AD Sofrani indicated "all residents and staff at facility are fully vaccinated for COVID-19." LPA Quiroz reviewed 5 of 5 resident's records during today's visit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. (See LIC 9102- Technical Violation)

This report was reviewed with L/AD Novac Sofrani, and a copy of this report, LIC 9102 and LIC 811 were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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