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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005411
Report Date: 03/17/2022
Date Signed: 03/17/2022 02:01:00 PM

Document Has Been Signed on 03/17/2022 02:01 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:FORTITUDE RESIDENTIAL CAREFACILITY NUMBER:
306005411
ADMINISTRATOR:REBEKAH HAYESFACILITY TYPE:
735
ADDRESS:9852 OMA PLACETELEPHONE:
(310) 938-0700
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 4CENSUS: 4DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Enrique ManabatTIME COMPLETED:
02:30 PM
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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. LPA spoke to Brandon Penalosa, Administrator via telephone and explained the nature of the visit.

LPA accompanied by caregiver began the tour of the inside and outside of the facility. There are four clients in care and there is no active Covid-19 case in the facility. LPA observed two clients in living room and remainder of clients in their bedrooms. All clients 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 throughout the facility. All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected client’s bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. Client’s bedrooms are all private bedrooms with one client per. LPA was checked in upon entry per Covid guidelines. Facility is taking temperature daily and documenting the results. LPA observed the emergency disaster and evacuation plan. Facility has the back-up emergency food and water supply as well as PPE supplies. LPA toured the outside of the facility and observed a shaded seating area for client’s enjoyment. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit. LPA emailed the signed and approved plan to the Administrator for their records.

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 the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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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