306004514-7-31-2024-22-AS-RMRT-D7PPNZ-20240731112847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004514
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:30:51 AM

Document Has Been Signed on 07/31/2024 11:30 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:	NORTHWOOD CARE HOME		FACILITY NUMBER:	306004514
ADMINISTRATOR:	TERESA ALPUERTO		FACILITY TYPE:	740
ADDRESS:	7 BRAGG		TELEPHONE:	(949) 653-5742
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY:	6	CENSUS: 6	DATE:	07/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Teresa Alpuerto, Administrator		TIME COMPLETED:	11:45 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) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #3 (S3) at 8:00 AM. During today’s visit, LPA met with Teresa Alpuerto, Administrator (AD) and Designee, Danilo De Guzman. The facility is a level 4 single-story building with an approved fire clearance of six non-ambulatory residents of which two may be on hospice. The facility currently has a census of six residents in care. At 8:05 AM LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that the administrator has a current certificate which expires on May 19, 2025. Danilo De Guzman's Administrator's Certificate is currently pending. Three residents had already left for Adult Day Program and two others left at 8:15 AM. At 8:55 AM LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperatures in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperatures measured between 111.9 and 113.0 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on May 13, 2024. The facility’s last fire drill was conducted on May 11, 2024. All items in First Aid kit were noted. At 9:00 AM LPA noted the PUB 475 poster is not the required size of 20" X 26". A Technical Violation will be issued, LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. (See LIC 809-C Continuation page)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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: NORTHWOOD CARE HOME	FACILITY NUMBER: 306004514
	VISIT DATE: 07/31/2024

NARRATIVE

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(Continued from LIC 809)

LPA reviewed four of four staff training and fingerprint records. LPA reviewed three of six resident records and noted all records had Admission Agreements from Regional Center but there were no Admission Agreements compliant to Title 22 and a Technical Violation will be given. All Resident P&I records were reviewed and were accurate.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Danilo De Guzman, Administrative Designee and a copy of the report and files reviewed (LIC 858 & LIC 859) and LIC 9102-TV were given at the time of the visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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