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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005323
Report Date: 08/05/2021
Date Signed: 09/01/2021 07:25:44 PM

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:CONGREGATE CARE TOUCHFACILITY NUMBER:
306005323
ADMINISTRATOR:CRUZ, CHONAFACILITY TYPE:
740
ADDRESS:238 SAN CARLOS WAYTELEPHONE:
(714) 646-9302
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 5DATE:
08/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosemarie Flores and Tristan RaqueroTIME COMPLETED:
12:45 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 Rosemarie Flores and Tristan Raquero. The focus of the visit was Infection Control. Administrator Chona Cruz and Florence Tolentino were contacted and arrived a short time after LPA.

During the visit LPA toured the facility with Staff Rosemarie Flores. LPA observed Covid signage at front entrance of facility as well as a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was made available. Facility has required Department postings. LPA observed a copy of Administrator Certificate for Chona Cruz that expires on 1/4/21. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply. LPA observed an outside visitation area with ample shading. Residents were observed watching tv in the family room and having lunch. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff at all times. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as PIN 21-32-ASC Updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Chona Cruz.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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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