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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004713
Report Date: 05/05/2022
Date Signed: 05/05/2022 04:20:53 PM


Document Has Been Signed on 05/05/2022 04:20 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:PACIFICARE HOMEFACILITY NUMBER:
306004713
ADMINISTRATOR:EMELITA MAGDALUYOFACILITY TYPE:
740
ADDRESS:24622 JEREMIAH DRIVETELEPHONE:
(949) 489-2273
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:6CENSUS: 5DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Martin Magdaluyo and Michael GeslaniTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Lourdes Dizon and explained the reason for the visit. Administrator Martin Magdaluyo has a current administrator certificate expiring on 07/22/2022. Administrator Martin Magdaluyo and Assistant Administrator Michael Geslani arrived during the visit.

At 2:30 PM, LPA toured the facility with Assistant Administrator Geslani. Facility has 5 residents in care during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. All rooms are single occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes resident and staff temperatures daily and documents. Facility has all required department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water as well as PPE. Toxins and sharps are secured. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed five resident files during the visit and all files are up to date including emergency information. All residents and staff are vaccinated for Covid-19.

LPA consulted with Assistant Administrator regarding the importance of hand washing signs in all facility restrooms as well as ensuring the emergency disaster plan is posted in the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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