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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004791
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:28:08 PM

Document Has Been Signed on 08/24/2021 04:28 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:LOS TIEMPOS SENIOR LIVING #3FACILITY NUMBER:
306004791
ADMINISTRATOR:FIGUEROA,LESLYFACILITY TYPE:
740
ADDRESS:10869 GOLDENEYE AVETELEPHONE:
(714) 928-7912
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Luz Hernandez and Lesly FigueroaTIME COMPLETED:
12:30 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 Luz Hernandez and explained the reason for the visit. Administrator Lesly Figueroa as well as Licensee Rosa Jeanette Figueroa arrived during the visit.

At 10:15 AM, LPA toured the facility with Administrator Figueroa. 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 as well as hand washing signage. All rooms are single occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents results. LPA observed ample sanitizer spread out throughout the facility. Facility has covid precaution postings as well as all required department postings. Facility mitigation plan has been submitted and pending approval. LPA observed an ample supply of emergency food and water in the garage. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gates are unlocked. 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 contained updated emergency information.. All residents and staff are vaccinated for Covid-19.

LPA consulted with Administrator regarding the importance of following department recommended guidelines for covid precautions and visitation for residents.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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