306004510-10-26-2022-22-AS-RQUZ-CKKNJ4-20221026102943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004510
Report Date: 10/26/2022
Date Signed: 10/26/2022 10:29:47 AM

Document Has Been Signed on 10/26/2022 10:29 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:	LOVING CARE SENIOR HOME		FACILITY NUMBER:	306004510
ADMINISTRATOR:	MAI T. NGUYEN		FACILITY TYPE:	740
ADDRESS:	9435 KIWI CIRCLE		TELEPHONE:	(714) 867-8074
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 5	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Van Thinh Pham, Live in caregiver and Thi Tho Do, Live in caregiver and Mai T. Nguyen (Via Telephone).		TIME COMPLETED:	10:30 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 live in caregiver. LPA Quiroz called Licensee/Administrator (L/AD) Mai Nguyen upon arrival to the facility. (L/AD) Nguyen indicated not being able to be present during today's annual inspection due to personal commitment.

This facility is licensed to provide services to 6 Non-Ambulatory residents and has a hospice waiver for (2) residents. The facility is currently providing services to one (1) resident.

L/AD Mai Nguyen has an Administrator Certificate with expiration date of 7/23/2024.

On or about 9:10am, LPA Quiroz reviewed 5 of 5 resident records. On or about 9:41am, LPA Quiroz along with live in caregiver toured the inside and outside of the facility. There are five (5)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed five (5) residents in living room area resting with staff supervision. Five of five residents present in the facility 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 Mai Nguyen indicated facility is taking temperatures daily; and documenting results.

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

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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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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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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: LOVING CARE SENIOR HOME	FACILITY NUMBER: 306004510
	VISIT DATE: 10/26/2022

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Facility has completed the LIC 808 Mitigation plan dated 12/21/2020. The LIC 808 Mitigation Plan was approved by LPA Quiroz on 11/30/2021.L/AD Mai Nguyen indicated "All staff and residents are fully vaccinated, have received all their boosters for COVID-19 and flu vaccine as well."

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.

This report was reviewed with L/AD Mai Nguyen via telephone, and a copy of this report and LIC 811- Confidential names 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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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