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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005229
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:15:36 PM

Document Has Been Signed on 05/31/2022 03:15 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:EL CINCO FAMILY HOME CAREFACILITY NUMBER:
306005229
ADMINISTRATOR:CINCO, EMMYLOUFACILITY TYPE:
735
ADDRESS:24892 STEM AVETELEPHONE:
(949) 716-9467
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Emmylou CincoTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced required annual inspection in this facility focusing primarily on the Infection Control. LPA was greeted and granted entry by Administrator (Admin) Emmylou Cinco. LPA stated the purpose of the visit and completed the Coronavirus 2019 (COVID-19) screening procedure. Upon entry, LPA observed the screening station and the required Department COVID-19 postings by the front entrance.

The facility is a single level structure and licensed for six ambulatory clients. This facility offers a Level 2 service. As of today, LPA observed three clients sitting around the dining table doing puzzles. All clients looked happy and well taken care of.

At 2:25 PM, LPA toured the interior and exterior portions of the facility with the Admin. There were two shared bedrooms and one bedroom was for the live in Admin. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms tested operational. Bathrooms observed to be in good repair; and provided with a grab bar and a non-skid floor mat. Facility had the required hand washing signs posted in all the bathrooms. Hot water measured at 111.7 degrees Fahrenheit in Bathroom #1 which was the designated bathroom for the clients and 106.8 degrees Fahrenheit in Bathroom #2 located in the Administrator's private living quarter. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. The fire extinguisher was charged. For the exterior portion, the facility had patio furniture under ample shading, and grounds were free of tripping hazards. The side gates were self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had sufficient emergency food and five gallons of water supply. The First Aid Kit had all the required components, and the facility had sufficient PPE supplies in the kitchen drawer.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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 2
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: EL CINCO FAMILY HOME CARE
FACILITY NUMBER: 306005229
VISIT DATE: 05/31/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. A tablet was available for clients to use in the kitchen/dining room.

LPA Cho reviewed the approved COVID 19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Emmylou Cinco, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2