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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004823
Report Date: 12/07/2021
Date Signed: 12/07/2021 04:28:50 PM

Document Has Been Signed on 12/07/2021 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:LEISURE TOWER II RESIDENTIAL CAREFACILITY NUMBER:
306004823
ADMINISTRATOR:NELSON PEREZFACILITY TYPE:
735
ADDRESS:608 E SYCAMORETELEPHONE:
(714) 321-1656
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 32CENSUS: 27DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nelson PerezTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Norman Woodridge met with Administrator (AD) Nelson Perez for the purpose of conducting a Covid-19 Annual Inspection at the facility. Upon arrival, LPA informed AD of the purpose of the visit, completed a temperature screening, and completed visitation log. LPA conducted a tour of the inside and outside of the facility, common areas, kitchen, resident apartments/bedrooms, bathrooms, and garages.

LPA and AD discussed the following:

LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed 30-day PPE supply and hygiene products. Hallways and walkways were free from obstruction. LPA observed Covid-19 related signage in restrooms and common areas of the facility. LPA observed liquid hand soap and toilet paper in the restrooms. LPA observed paper towels stored in garage 1 and provided technical assistance regarding placing paper towels in each restroom. LPA provided technical assistance regarding screening and temperature checks for staff members. LPA reviewed temperature check logs for clients and visitors. LPA reviewed Covid-19 related policies, procedures, Covid-19 training logs, and Covid-19 Mitigation Plan. LPA secured a copy of the facility’s staff and client roster. LPA discussed updated Covid-19 requirements including testing, visitation, training, and screening.

No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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