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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005426
Report Date: 05/09/2022
Date Signed: 05/10/2022 08:11:47 AM


Document Has Been Signed on 05/10/2022 08:11 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:AMITY ASSISTED LIVINGFACILITY NUMBER:
306005426
ADMINISTRATOR:PEREZ, STEPHANIE J.FACILITY TYPE:
740
ADDRESS:23391 CAVANAUGH ROADTELEPHONE:
(949) 380-0043
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Cynthia Gomez - Caregiver, Hermelinda Perez- Administrator TIME COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Cynthia Gomez and explained the reason for the visit. At 9:20AM Administrator Hermelinda Perez arrived during the visit.

At 9:15 AM, LPA toured the facility with Caregiver Cynthia Gomez. Facility is 5 bedroom, 2 bathroom single story home with an attached garage. Facility has 6 residents present during today's visit. LPA observed residents relaxing in the facility and in their respective rooms. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes residents temperatures daily and documents. The facility mitigation plan has been completed and approved. LPA observed emergency food and water.LPA observed unsecured pre-poured prescription medication. LPA observed locked medication closet. LPA toured the outside grounds and observed outside shaded visitation area. Exit gate is unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all residents files and all contained required documentation including updated emergency information. All staff and residents are vaccinated for Covid 19.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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Document Has Been Signed on 05/10/2022 08:11 AM - It Cannot Be Edited

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: AMITY ASSISTED LIVING
FACILITY NUMBER: 306005426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed pre-poured medication in an unlocked kitchen cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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Licensee to secure all medications and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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