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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005346
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:54:01 PM

Document Has Been Signed on 08/02/2023 03:54 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:DOCTORS TLC ASSISTED LIVING IFACILITY NUMBER:
306005346
ADMINISTRATOR:MCGARRY, MARISSAFACILITY TYPE:
740
ADDRESS:17207 BUTTONWOOD STTELEPHONE:
(714) 381-6505
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
08/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Ronel Alforte, Caregiver, Ali Naghibi, Administrator (Via telephone) and Licensee Pastrmac (Via Telephone)TIME COMPLETED:
03:53 PM
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 On today's date while conducting 10 day inspection visit for complaint control #22-AS-20230726144936, Licensing Program Analyst (LPA) Rosie Quiroz along with Caregiver Renol Alforte conducted tour of interior and exterior facility premises.
On or about 11:20am, while LPA Quiroz conducted facility tour along with Caregiver Ronel Alforte, LPA Quiroz observed family room in facility to be under construction as evidenced by family room taped up with plastic. Caregiver Ronel Alforte indicated, "The new owners are remodeling. Going to be a private bedroom." During today's visit, LPA Quiroz called and spoke to Administrator Ali and Licensee Eric Pastmac who verified facility is undergoing renovation indicating perspective Licensee is seeking permits from Fountain Valley City Department and fire clearance from Fountain Valley Fire Department along with new facility license application.
Licensee Pastrmac indicated not being aware of California Code of Regulation-87211
Reporting Requirements. It was determined through interview with Licensee Pastrmac that Licensee did not notify Community Care Licensing of intent to perform construction in order to alter family room area in the facility observed by LPA Quiroz during today's visit and verified with Licensee Pastrmac.



Based on the observations made during today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Licensee Eric Pastrmac via telephone and with Caregiver Ronel Alforte in person, and a copy of this report along with Appeal Rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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Document Has Been Signed on 08/02/2023 03:54 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 08/02/2023 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DOCTORS TLC ASSISTED LIVING I
FACILITY NUMBER: 306005346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
Section Cited
CCR
87211(a)(1)(D)

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87211-Reporting Requirements:
Each licensee shall furnish to the licensing agency such reports as the Department may require...Any incident which threatens the welfare, safety or health of any resident...This requirement is not being met as evidenced by:
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Licensee Eric Pastrmac to submit a statement of understanding regarding the regulation 87211 and forward to LPA by POC due date of 8/4/2023.
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Based on interviews conducted, and observations made by LPA Quiroz on 8/2/2023 the Licensee failed to notify Community Care Licensing of intent to perform construction to alter family room area. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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