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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005441
Report Date: 04/15/2024
Date Signed: 04/15/2024 12:37:37 PM


Document Has Been Signed on 04/15/2024 12:37 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:FOUNTAIN VALLEY SENIOR HOMESFACILITY NUMBER:
306005441
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:18561 SANTA ISADORATELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Romualdo Peleno, CaregiverTIME COMPLETED:
12:41 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a subsequent unannounced visit after delivering findings for complaint control # 22-AS-20240408103754.
LPA Quiroz was greeted by Caregiver 1 (CG1) and discussed purpose of today's visit. Licensee/Administrator (L/AD) Uldarico Almiranez arrived during today's visit.
On or about 10:21am while conducting interviews with Resident 1, LPA Quiroz observed trash and food crumbs underneath and on recliner couches in living room area, this was verified with CG1 and L/AD Almiranez. CG1 indicated "We'll take note of that and be careful with making sure to clean well." On or about 11:30am while LPA Quiroz reviewed resident files in dining-room area, LPA Quiroz observed broken case on lower part of dishwasher and tape on top of dishwasher; this was verified with CG1 and L/AD Almiranez who indicated being aware of case being loose and will have it repaired.

During today's inspection visit, while conducting tour of the facility and conducting interviews for complaint control #22-AS-20240408103754, the following deficiency was observed and is being cited via this case management deficiency.
  • 87303(a)-Maintenance and Operation

The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with CG1, and a copy of this report, 809-D Page, Appeal Rights was provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/15/2024 12:37 PM - 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: FOUNTAIN VALLEY SENIOR HOMES
FACILITY NUMBER: 306005441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
87303(a)

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Maintenance and Operation-87303(a): (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by, during today's inspection tour LPA Quiroz observed trash/crumbs underneath and on recliner couches. LPA Quiroz observed loose case on lower
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L/AD agreed staff wil clean couches and living room area and provide inservice training to facility staff on CCR 87303 and submit proof of training by POC due date of 4/19/2024. L/AD will repair dishwasher in kitchen area and submit proof by POC due date of 4/19/2024.
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part of dishwasher and tape on top areas of dishwasher in kitchen area. This was verified by CG1 and L/AD Almiranez. L'AD Almiranez indicated "I will call and have it repaired."
This poses a potential 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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