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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 09/30/2022
Date Signed: 09/30/2022 01:05:15 PM


Document Has Been Signed on 09/30/2022 01:05 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:FULLERTON VILLAFACILITY NUMBER:
306004839
ADMINISTRATOR:DARLENE LINDLEYFACILITY TYPE:
740
ADDRESS:2441 W. ORANGETHORPE AVE.TELEPHONE:
(714) 992-5380
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:197CENSUS: DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Darlene LindleyTIME COMPLETED:
01:15 PM
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On 09/30/2022 at 9:14am, Licensing Program Analyst (LPA) Jessica Cho arrived at Fullerton Villa to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 9:18am, LPA Cho was greeted by Receptionist Hyun So followed by the Administrator (Admin) Darlene Lindley. LPA completed the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. Facility screens temperatures for visitors on a sign in sheet. Staff and residents temperatures are screened daily and documented. LPA observed the required COVID-19 precautionary signs on the entrance door and throughout the facility. The Complaint Posters (PUB475) met the size requirement. The facility is licensed for 196 non-ambulatory residents and has a hospice waiver for 25. As of today, there are 163 residents living in the facility and 11 are receiving hospice care.

At 9:43am, LPA Cho conducted a tour of the physical plant along with Admin Darlene Lindley . The two-story facility is comprised of the following areas: (3) offices, Living/Conference Room, Medication Room, (2) Employee Lounges, Emergency Supply Room, Telephone Room, (2) Laundry Rooms, Maintenance Room, Kitchen, (2) Dining Rooms, Family Room, (2) Activity Rooms, Television Room, Mini Spa, and Personal Care/PPE Equipment Room. There are a total of 92 bedrooms and bathrooms. Out of the 92 bedrooms/bathrooms, LPA randomly selected and inspected a total of 20 resident bedrooms and bathrooms. Ten resident bedrooms/bathrooms were inspected on each floor of which two bedrooms/bathrooms belonged to hospice residents. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly and grab bars were secure. The showers were free of mold/mildew, and non-skid mats were in place. Admin was requested to have all bathrooms deep cleaned as stains were observed in the sinks and toilets. Resident bath towels and personal hygiene supplies were adequately stocked including hand soaps, but paper towels were not observed. Hand washing signs were observed in all bathrooms.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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: FULLERTON VILLA
FACILITY NUMBER: 306004839
VISIT DATE: 09/30/2022
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LPA Cho tested the hot water temperature in 20 resident bathrooms and the temperature measured between the ranges of 100.0 to 122.5 degrees Fahrenheit.

LPA Cho inspected the kitchen along with Admin Lindely. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Facility has ample back-up emergency food and water supply. The fire extinguishers were fully charged and the auditory devices were operational. The hard-wired smoke detectors were tested by The Brennan Fire & Security Inc. on 12/01/2021 and was noted to be operational. The carbon monoxide and the manual smoke detectors were tested along with Maintenance Staff Rodrigo Bartolome and Admin and were observed to be operational. LPA verified the monthly inspection log conducted by Maintenance Staff Rodrigo Bartolome. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds with Admin Lindley. LPA observed two courtyards on each floor. There was shading and sufficient seating for residents, and the walkways around the facility were clear of hazards. The exit gates were self-closing and self-latching.



LPA Cho reviewed the Emergency and Disaster Plan for Residential Care for the Elderly (LIC610E), and Admin was advised to update the information using the current LIC610E form per the Provider Information Notice (PIN 22-02-ASC) released on 01/06/2022. LPA observed The First Aid Kit met all the required components, and the facility had sufficient PPEs. LPA reviewed Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides a smart phone upon request.

LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued. An exit interview was conducted with Administrator Darlene Lindley, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC809 (FAS) - (06/04)
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