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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005187
Report Date: 04/05/2022
Date Signed: 04/12/2022 08:05:45 AM


Document Has Been Signed on 04/12/2022 08:05 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:FOREVER YOUNG MEMORY CAREFACILITY NUMBER:
306005187
ADMINISTRATOR:YOUNG, WILLIAMFACILITY TYPE:
740
ADDRESS:12792 DEAN STREETTELEPHONE:
(714) 420-2210
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 6DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:William YoungTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Sam Gamboa and Susan Lanser. Administrator William Young was contacted via telephone and arrived a short time after LPA. The focus of the visit was Infection Control. The facility was toured with Ms. Gamboa and then Mr. Young when he arrived. The following was observed:

Covid signs were posted outside and inside the facility and a sanitization station(portable sink) was set up just inside the front entrance. LPA's temperature was taken upon arrival and a sign in sheet and questionnaire was available. Facility has required Department postings. Restrooms observed contained soap and toilet paper. Paper towels were also available. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. There were six residents present. Administrator Certificate for William Young expires 12/2/22. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication cart for resident medication. Resident files were locked.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of masks and hand washing for staff, visitors, as well as residents. Administrator is reminded to review all Department PINS in regards to Masks, Staff and Resident Testing, Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to William Young.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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