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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005327
Report Date: 10/31/2022
Date Signed: 10/31/2022 01:59:01 PM


Document Has Been Signed on 10/31/2022 01:59 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: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: 4DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Stefan BarnutiuTIME COMPLETED:
02:15 PM
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On 10/31/2022 at 12:43pm, Licensing Program Analyst (LPA) Jessica Cho arrived at AAA Laguna Hills Assistance Care Home to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year with an emphasis on Infection Control. At 12:45pm, LPA Cho was greeted and granted entry by Administrator (Admin) Stefan Barnutiu. LPA completed the Coronavirus 2019 (COVID-19) screening procedure. There are no active COVID-19 cases as of today. Facility screens but does not document daily temperatures of visitors on a sign in sheet. LPA observed the required COVID-19 precautionary on the entrance door. The Complaint Poster (PUB475) was not observed. The facility is licensed for four non-ambulatory, 1 bedridden and has a hospice waiver for three. There are currently four residents living in the facility of which none are receiving hospice care. The Administrator's Certificate for Stefan Barnutiu expires on 01/08/2023.

At 12:51pm, LPA Cho conducted a tour of the physical plant with Admin Stefan Barnutiu. This is a single story home that consists of six resident bedrooms and 4 resident bathrooms. There is also a private staff bedroom. The resident bedrooms were checked. The resident bedrooms had the required furnishings. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperatures and the water temperatures measured at 111.9 degrees Fahrenheit in Bathroom #1, 118.5 degrees Fahrenheit in Bathroom #2, 116.7 degrees Fahrenheit in Bathroom #3, and 115.7 degrees Fahrenheit in Bathroom #4. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 09/02/2022. Smoke/carbon monoxide detectors and auditory devices were tested. The auditory device on the sliding door in Bedroom #3 was not operating. The faucet in the bathroom of Bedroom #3 was loose. Medications, toxins, and sharps were locked and inaccessible to the residents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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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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: AAA LAGUNA HILLS ASSISTANCE CARE HOME
FACILITY NUMBER: 306005327
VISIT DATE: 10/31/2022
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LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. Walkways around the facility were clear of hazards, and there were no security bars or weapons on the premises. The exit gate was self-closing and self-latching. LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Administrator Stefan Barnutiu, and a copy of this report was provided via email.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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