306004791-8-15-2022-22-AS-RQUZ-CHBQLZ-20220815121647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004791
Report Date: 08/15/2022
Date Signed: 08/15/2022 12:16:52 PM

Document Has Been Signed on 08/15/2022 12:16 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 #3		FACILITY NUMBER:	306004791
ADMINISTRATOR:	FIGUEROA,LESLY		FACILITY TYPE:	740
ADDRESS:	10869 GOLDENEYE AVE		TELEPHONE:	(714) 928-7912
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	08/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Janeth Meza, Caregiver and Rosa Figueroa, Licensee		TIME COMPLETED:	12:25 PM

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On today's date, Licensing Program Analysts (LPA) LPA Rosie Quiroz and Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA's were greeted, COVID-19 screened and granted entry into the facility by Caregiver Veronica Gandara. LPAs met with Caregiver Janeth Meza and explained the nature of the visit. Facility indicated screening all incoming visitors prior to entering the facility. This facility is licensed to provide services to six (6) Non-Ambulatory Residents and has a hospice waiver for four (4) residents. Facility is currently providing hospice services to (1) one resident at this time. Administrator (AD) Rosa Figueroa has an Administrator Certificate with expiration date of September 8, 2023.

On or about 11:02am, LPA Rosie Quiroz along with caregiver Veronica Gandara began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed four of six residents in their bedroom resting, one of six residents out for a walk with caregiver supervision in the back yard area and one resident in dining-room area reading a book. LPA Quiroz interacted and interviewed with resident's during today's visit. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 76 degrees fahrenheit.

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be between 108-112.2 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and kitchen area readily available for staff and residents.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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: LOS TIEMPOS SENIOR LIVING #3	FACILITY NUMBER: 306004791
	VISIT DATE: 08/15/2022

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LPA Quiroz toured the outside of the facility and observed seating and shaded area for residents and visitor's enjoyment in backyard area. LPA Quiroz was informed that six of six residents and two staff have had their COVID-19 vaccinations. L/AD Figueroa indicated 2 of 6 residents have received their 1st booster and all staff working at the facility have received their 1st booster. Facility indicated to be recording resident's temperatures two times daily. On 7/06/2021 the Mitigation plan was uploaded in FAS by LPA Quiroz, and was approved on today's date.

During today's visit, LPAs provided Consultation on Title 22 and ongoing COVID-19 Infection control and indoor facility temperature during hot weather season throughout today's visit. Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with (L/AD) Rosa Figueroa, and a copy of this report and LIC 811 Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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