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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005327
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:23:20 PM

Document Has Been Signed on 11/07/2024 12:23 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AAA LAGUNA HILLS ASSISTANCE CARE HOMEFACILITY NUMBER:
306005327
ADMINISTRATOR/
DIRECTOR:		BARNUTIU, STEFANFACILITY TYPE:
740
ADDRESS:25651 CALIFIA DRIVETELEPHONE:
(949) 472-0115
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Tita PearsonTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analysts (LPAs) Ruth Martinez and Nancy Guillen are conducting this unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and was greeted and granted entry by caregiver and LPA explained the nature of the visit. There are five residents at the facility and there are no residents receiving hospice services currently.

Upon entry LPAs observed resident in the living room of the facility. LPAs began the tour of the inside and outside of the facility. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in the refrigerator located in garage. The facility is maintained at a comfortable temperature. LPAs inspected that medication is centrally stored in a safe locked storage cabinet located in a kitchen cabinet. LPAs reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPAs inspected the bathroom and measured the hot water temperature which measured 116.6 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage cabinet garage. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are several shaded seating areas for residents’ enjoyment. LPAs observed a fire extinguisher with

Continued on LIC809-C
Armando J LuceroTELEPHONE: (949) 430-1222
Ruth MartinezTELEPHONE: (657) 285-1397
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AAA LAGUNA HILLS ASSISTANCE CARE HOME
FACILITY NUMBER: 306005327
VISIT DATE: 11/07/2024
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service date of October 27, 2024, in the main entry of the facility. Fire drills are conducted every three months. LPAs began review of records. LPAs reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPAs reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPAs observed records reviewed have a current First Aid certificate.

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

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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