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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005333
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:20:04 AM

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:ORANGE HILL ELDERLY CAREFACILITY NUMBER:
306005333
ADMINISTRATOR:RODRIGUEZ, FRANCISFACILITY TYPE:
740
ADDRESS:2586 N ORANGE HILL RDTELEPHONE:
(714) 602-6072
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 4DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Monica Cuellar, CaregiverTIME COMPLETED:
11:40 AM
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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 and explained the nature of the visit.

LPA Martinez toured the inside and outside of facility. There are four residents in care and there are no active covid-19 cases. LPA observed four residents in their bedrooms. All residents appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA inspected residents’ bedrooms and bedrooms appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. There are no residents residing on the second floor of the facility, residents have no access to the second floor. LPA toured the outside of the facility and observed ample seating area for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan and LPA reviewed/approved the plan on site.

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 facility representative 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: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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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