<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005208
Report Date: 09/20/2021
Date Signed: 11/03/2021 03:55:56 PM

COMPREHENSIVE INSPECTION
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:BAY VISTA VILLAFACILITY NUMBER:
306005208
ADMINISTRATOR:LE, TARAHFACILITY TYPE:
740
ADDRESS:17971 BAY STREETTELEPHONE:
(714) 200-8454
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 0DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:New tenant at 17971 Bay Street, Fountain Valley, CA 92708 and Licensee/Administrator Le via telephoneTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On today’s date at 2:29pm, Licensing Program Analyst (LPA) LPA Rosie Quiroz attempted to conduct an unannounced visit for the purpose of conducting a required annual inspection.

On or about 2:32 pm, LPA Quiroz called and spoke to Administrator (AD) Tarah Le who indicated she had notified Community Care Licensing via letter dated 2,17,2021 that she would be moving forward with closure of facility due to COVID-19 and its effect on the RCFE.

AD Le indicated providing resident and their responsible parties ample notification for relocation due to facility closure. AD Le indicated working with a referral agency who assisted 1 of 3 residents with facility relocation. AD Le indicated 2 of 3 residents relocated with their families. AD Le indicated last resident moved out beginning of March 2021 and indicated having zero residents at the facility since March 6, 2021.

On or about 2:39pm, while speaking to AD Le via telephone, new tenant at the property opened the door. LPA Quiroz inquired about any residents residing at property. New tenant at facility indicated her and her family residing at facility and no residents/clients requiring medical care residing on the promises.

LPA Quiroz was not granted entry into the facility, however while observing inside of home through front entrance, LPA Quiroz did not observe any wheel chairs, or medical devices.

On or about 3:27pm on today's date, AD Le forwarded LPA Quiroz copy of facility closure letter dated 2/17/2021 addressing facility closure interest addressed to California Department of Social Services Community Care Licensing.

LPA Quiroz conducted exit report with AD Le via telephone. AD Tarah Le not able to meet with LPA Quiroz during today's visit due to relocation out of state. LPA Quiroz mailed out copy of report via certified mail to address on file for Licensee/Administrator Tarah Le.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1