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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004629
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:45:05 PM


Document Has Been Signed on 05/24/2022 01:45 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 LAGUNA HILLSFACILITY NUMBER:
306004629
ADMINISTRATOR:BENIGNO BULANADIFACILITY TYPE:
740
ADDRESS:24961 SOUTHPORT STREETTELEPHONE:
(949) 683-8736
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Herminia ZuehlTIME COMPLETED:
01:50 PM
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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 Dorlie Gasco after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA observed the screening station and the required COVID-19 postings along with the PUB475 See Something, Say Something poster in the size of 8.5"x11" by the front entrance. The Administrator's Certificate for Benigno Bulanadi expires on 7/17/2023. Licensee Herminia (Amy) Zuehl and Administrator Benigno Bulanadi arrived at the facility at 12:30 pm.

At 12:10 pm, LPA toured the interior and exterior portions of the facility with Caregiver Dorlie Gasco. The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden; and has a hospice waiver for three residents. Currently, there are 3 residents in hospice care. Facility had six residents in care as of today. Four residents were watching television in the living room and the two residents were in their respective bedrooms napping. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. 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 118.9 degrees Fahrenheit in Restroom #1, 117.2 degrees Fahrenheit in Restroom #2, and 118.3 degrees Fahrenheit in Restroom #3. 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. Fire extinguisher was mounted and charged in the kitchen. For the exterior portion, the facility had patio furniture under a gazebo for shade, and grounds were free of tripping hazards. The side gates were self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPE supplies in the garage.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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 LAGUNA HILLS
FACILITY NUMBER: 306004629
VISIT DATE: 05/24/2022
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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. LPA observed an iPad for resident use during the visit.

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 Licensee Herminia (Amy) Zuehl, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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