306004547-7-22-2022-22-AS-CDPO-CGKQBQ-20220722120155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004547
Report Date: 07/22/2022
Date Signed: 07/22/2022 12:02:05 PM

Document Has Been Signed on 07/22/2022 12:02 PM - 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:	PACIFIC SHORES OF LAKE FOREST		FACILITY NUMBER:	306004547
ADMINISTRATOR:	BENIGNO BULANADI		FACILITY TYPE:	740
ADDRESS:	21521 MORESBY WAY		TELEPHONE:	(949) 716-8903
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	07/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Facility Administrator - Benigno Bulanadi		TIME COMPLETED:	12:15 PM

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) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Benigno Bulanadi about visit. As of 7/22/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the main entrance door. The PUB475 "See Something, Say Something" poster was also observed at the central location of the facility. LPA observed the Administrator's Certificate for Benigno Bulanadi which expires on 7/17/23. LPA De Perio toured the interior and exterior portions of the facility with AD Bulandai and both staff members. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 4 may be on hospice and 1 may be bedridden. Currently, there are a total of 6 residents in care, of which 4 are on hospice and 1 is bedridden. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilet was operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 116.4 degrees Fahrenheit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

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: PACIFIC SHORES OF LAKE FOREST	FACILITY NUMBER: 306004547
	VISIT DATE: 07/22/2022

NARRATIVE

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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Fire extinguisher was charged, mounted and located in the kitchen. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is one gate in the backyard, which is self-closing and self-latching. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at in the hallway of the facility. Facility had back-up emergency food and water supply, located in the garage and in the kitchen pantry.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE. Medications were locked in a cabinet located in the hallway. Toxins were also observed to be locked and inaccessible to residents and located in the garage and laundry room. There is also a cabinet in the kitchen that holds additional prescriptions and sharps and is also locked and inaccessible to residents.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Bulanadi LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service 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.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

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: PACIFIC SHORES OF LAKE FOREST	FACILITY NUMBER: 306004547
	VISIT DATE: 07/22/2022

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For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Bulanadi and staff on duty to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assign LPA.

LPA De Perio also discussed the reporting requirements (such as reporting COVID cases) with AD Bulanadi and staff on duty and provided instructions and sent COVID Script for reference if facility had positive cases to report.

LPA De Perio conducted an exit interview with AD Bulanadi and staff on duty and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

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