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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005342
Report Date: 11/14/2022
Date Signed: 11/14/2022 11:22:05 AM


Document Has Been Signed on 11/14/2022 11:22 AM - 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:CARE CELINE IFACILITY NUMBER:
306005342
ADMINISTRATOR:RICARDO DOUGUILESFACILITY TYPE:
740
ADDRESS:4381 CAMPHOR AVETELEPHONE:
(714) 801-5208
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 6DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Cherry AguilaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Care Celine I to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 9:50am, LPA Cho was greeted and granted entry by Caregiver Mona Liza Reyes. LPA also met with Caregiver Cosmedamia Ramos followed by Administrator (Admin) Cherry Aguila and stated the purpose of the visit. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station with a thermometer. Facility has discontinued COVID-19 screening and documenting temperatures of visitors on the sign-in sheet. LPA observed the required COVID-19 precautionary signs posted throughout the facility. The Complaint Poster (PUB475) met the size requirement. The facility is licensed for five non-ambulatory and 1 bedridden residents and has a hospice waiver for six. There are currently six residents living in the facility of which five are receiving hospice care.

Around 10am, LPA Cho conducted a tour of the physical plant. There are a total of four resident bedrooms and two resident bathrooms. There is a private staff bedroom and bathroom. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. All sinks in the resident bathrooms drained slowly. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps and paper towels. LPA observed hand washing signs in the bathrooms. The hot water temperature in the resident bathroom measured at 111.0 degrees Fahrenheit in Bathroom #1. Bathroom #2 was not measured due to slow drainage. Perishable and non-perishable food supplies were checked and adequately stocked. Smoke/carbon monoxide detectors and auditory devices were tested and operational. The fire extinguisher was mounted, fully charged, and purchased on 11/14/2022. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. The exit gate was not self-closing and self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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: CARE CELINE I
FACILITY NUMBER: 306005342
VISIT DATE: 11/14/2022
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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 Cherry Aguila, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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