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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005327
Report Date: 10/26/2021
Date Signed: 10/26/2021 01:49:14 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:AAA LAGUNA HILLS ASSISTANCE CARE HOMEFACILITY NUMBER:
306005327
ADMINISTRATOR:BARNUTIU, STEFANFACILITY TYPE:
740
ADDRESS:25651 CALIFIA DRIVETELEPHONE:
(949) 472-0115
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 5DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Stefan Barnutiu, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver. LPA met with caregiver and explained the nature of the visit. Administrator arrived shortly after and met with LPA.

LPA Martinez accompanied by caregiver began the tour of the inside and outside of the facility. There are currently five residents in care and there are no active covid-19 cases in the facility. LPA observed one residents in living room relaxing and four residents in their bedrooms. All residents appeared to be clean and well taken care of. Upon entry LPA observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting the results. LPA observed the emergency disaster and evacuation plan. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All bathrooms observed to have supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and they appeared to be clean and sanitary. All bedrooms observed to have all the required components. Residents bedrooms are four private bedrooms with one resident per and one shared bedroom with two residents per. Facility has back-up emergency food supply and water supply as well as PPE supplies in the attached garage. LPA toured the outside of the facility and observed several shaded seating area for resident’s enjoyment. The facility has completed the LIC808 Mitigation Plan, plan was approved by the Department on April 26, 2021 and Administrator was notified.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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