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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005439
Report Date: 09/15/2021
Date Signed: 09/15/2021 01:10:55 PM

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 JORDAN SENIOR HOMESFACILITY NUMBER:
306005439
ADMINISTRATOR:GIDEON LIMPIADOFACILITY TYPE:
740
ADDRESS:8728 CANARY AVENUETELEPHONE:
(562) 365-4155
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Sara Jane Dela CruzTIME COMPLETED:
12:54 PM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA Quiroz was greeted and granted entry into the facility by House Manager (HM) HM Sara Dela Cruz and explained the reason for the visit. During visit, LPA Quiroz called and spoke to Administrator Gideon Limpiado who indicated Sara Dela Cruz would be the one present during today's inspection visit. This facility is licensed to provide services to residents age 60 and over, 6 Non Ambulatory Residents, of which 1 may be Bedridden. Administrator Gideon Limpiado has an active Administrator Certificate with expiration date of 4/22/2022.

At 10:22AM, LPA Quiroz toured the facility with (HM) Dela Cruz . The Facility has currently 6 residents in care during today's visit. LPA Quiroz observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer as well as hand washing. Facility HAS 4 single occupancy bedrooms, 1 shared bedroom for 2 occupants, 2 caregiver bedrooms and 2 bathrooms for staff, visitors and residents.

The Facility screens all visitors to the facility. LPA Quiroz observed the screening/ sanitizing station in the facility upon entrance. The Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents results. LPA Quiroz observed ample sanitizer spread out throughout the facility. Facility has COVID-19 precaution postings at facility entrance only. Facility mitigation plan has been submitted and pending approval. LPA Quiroz toured the outside grounds and observed the shaded outside visitation area. Exit gates are unlocked. LPA Quiroz observed the locked medication storage area. Facility has a plan for COVID-19 testing residents and staff as needed as well as a plan for isolation and quarantine. LPA Quiroz reviewed six of six resident files during the visit, two staff records and all contained updated emergency information. 5 of 6 residents and all staff are vaccinated for COVID-19.
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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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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 JORDAN SENIOR HOMES
FACILITY NUMBER: 306005439
VISIT DATE: 09/15/2021
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During today's visit LPA Quiroz consulted with HM Dela Cruz and exit visit with Administrator Limpiado regarding the importance of following department recommended guidelines for COVID-19 precautions , visitation for residents, supply of emergency food and water and COVID-19 posting requirement throughout the facility. ( LIC 9102-Technical Assistance)

During today's visit, no deficiencies were observed and the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with (HM) Dela Cruz and with AD Gideon Limpiado via telephone, and a copy of this report, LIC 9102, confidential names list were provided to (HM) Dela Cruz at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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