306004545-5-26-2022-22-AS-JCHO-CESQ2C-20220526114654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004545
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:47:05 AM

Document Has Been Signed on 05/26/2022 11:47 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:	ASTORIA RETIREMENT AT DOVER SHORES		FACILITY NUMBER:	306004545
ADMINISTRATOR:	OANA ABRUDAN		FACILITY TYPE:	740
ADDRESS:	1412 SANTIAGO DRIVE		TELEPHONE:	(714) 306-2253
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92660
CAPACITY:	6	CENSUS: 5	DATE:	05/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Oana Abrudan		TIME COMPLETED:	11:55 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) Jessica Cho conducted an unannounced required annual inspection in this facility focusing primarily on the Infection Control. LPA was greeted and granted entry by Caregiver Ariel Barro after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA observed the screening station and the required COVID-19 postings by the front entrance. The Administrator's Certificate for Oana M Abrudan expires on 1/7/2023 and Rossana S Maala's certificate expired on 5/14/2019. Caregiver Maala stated that all course work were completed and is waiting for her certificate. LPA observed the certificates during the visit. Administrator (Admin) Oana Abrudan joined around 11:15 am. At 9:43 am, LPA toured the interior and exterior portions of the facility with Caregiver Maala. The facility is a single level structure and licensed for six non-ambulatory and has a hospice waiver for three residents. As of today, the facility had five residents of which two are in hospice care. Upon entry, LPA observed two residents watching television in the living room, one resident eating in the dining room, and two residents in their respective bedrooms resting. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA observed a camera in Bedroom #2; and per Admin, the camera waiver request was sent to LPA Kimberly Lyman via email on 1/22/2020. LPA received a forwarded copy of the updated Admission Agreement, Plan of Operation which was sent via email during the visit, and Admin ensured that a verbal consent was authorized from the resident's wife. LPA consulted Admin to remove the camera until authorized by the Department and to provide a written consent by the resident's wife, and the camera was removed during the visit. Smoke, carbon monoxide, and auditory exit alarms tested operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 118.7 degrees Fahrenheit in Staff Restroom #1, 113.9 degrees Fahrenheit in Restroom #2, 112.8 degrees Fahrenheit in Restroom #3, and 112.4 degrees Fahrenheit in Restroom #4. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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: ASTORIA RETIREMENT AT DOVER SHORES	FACILITY NUMBER: 306004545
	VISIT DATE: 05/26/2022

NARRATIVE

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Fire extinguisher was mounted and charged in the kitchen. For the exterior portion, the facility had patio furniture under an umbrella, and grounds were free of tripping hazards. The side gate was self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had back-up emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPE supplies stored in the garage. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Residents are allowed access to use staff mobile phones and iPad upon request.

LPA Cho reviewed the COVID 19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Admin Oana Abrudan, and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC809 (FAS) - (06/04)

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