<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004684
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:25:05 PM


Document Has Been Signed on 05/24/2022 04:25 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:EL CINCO HOME CAREFACILITY NUMBER:
306004684
ADMINISTRATOR:EMMYLOU CINCOFACILITY TYPE:
735
ADDRESS:25151 COSTEAU STREETTELEPHONE:
(949) 305-3821
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 4DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Emmylou CincoTIME COMPLETED:
04:40 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) Jessica Cho made an unannounced required annual inspection in this facility focusing on the Infection Control. LPA was greeted and granted entry by Caregiver Carmen Dimalanta after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit. Upon entry, LPA observed the screening station and the required Department COVID-19 postings by the front entrance.

The facility is a single level structure and licensed for six ambulatory clients. This facility offers a Level 2 service. As of today, LPA observed 4 clients entering and leaving the facility to go to the gym and one staff on duty. All clients looked happy and well taken care of.

At 2:40 PM, LPA toured the interior and exterior portions of the facility with Caregiver Carmen Dimalanta. Administrator (Admin) Emmylou Cinco joined shortly around 3:10 pm. 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 observed to be in good repair; and provided with a grab bar and a non-skid floor mat. Hot water measured at 117.6 degrees Fahrenheit in Restroom #1 which was the only restroom designated for the clients. 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 ample shading, 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 had sufficient emergency food and six gallons of water supply. The food bar, water pouches, and Aspirin Tablets inside four emergency backpacks hanging in the hallway wall expired on 4/2018 were removed during the visit. 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)
Page: 1 of 3


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: EL CINCO HOME CARE
FACILITY NUMBER: 306004684
VISIT DATE: 05/24/2022
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
26
27
28
29
30
31
32
LPA discussed Assembly Bill 665 that requires a licensee of any adult 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. A desktop computer was available for clients in the kitchen/dining room.

LPA Cho reviewed the approved 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 Admin will follow-up with the correction. An exit interview was conducted with Administrator Emmylou Cinco, 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)
Page: 2 of 3