306004713-8-20-2024-22-AS-AROS-D8BNGY-20240820102755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004713
Report Date: 08/20/2024
Date Signed: 08/20/2024 10:28:00 AM

Document Has Been Signed on 08/20/2024 10:28 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PACIFICARE HOME		FACILITY NUMBER:	306004713
ADMINISTRATOR:	EMELITA MAGDALUYO		FACILITY TYPE:	740
ADDRESS:	24622 JEREMIAH DRIVE		TELEPHONE:	(949) 489-2273
CITY:	DANA POINT	STATE: CA	ZIP CODE:	92629
CAPACITY:	6	CENSUS: 6	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator Arturo Magdaluyo		TIME COMPLETED:	10:40 AM

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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Annual inspection. LPA was greeted and allowed entry into the facility by care giver Aiza Clemente to whom LPA discussed the purpose of the visit. Later, Administrator Arturo Magdaluyo joined the visit. According to the facility’s license, the facility has a maximum capacity of six (6) non-ambulatory clients. Facility also has a hospice waiver for three (3).

LPA, accompanied Administrator Arturo Magdaluyo, to continue the tour of the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant. No pools or body water present at facility.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. LPA also conducted an inspection of the centrally stored medications. They were properly locked in medication closet. Medication logs and medications reviewed were current.

[Continued on 809-C]

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFICARE HOME	FACILITY NUMBER: 306004713
	VISIT DATE: 08/20/2024

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LPA conducted further interviews and per Administrator Arturo Magdaluyo, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. LPA interviewed staff members and residents. LPA interviews did not raise any licensing concerns. Staff and resident records review verified that all staff records and residents are complete and compliant. Licensee presented proof of current liability insurance. Administrator’s certification is current. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Arturo Magdaluyo, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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