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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005441
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:59:25 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/25/2022 12:59 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:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Conrad Caniga, Caregiver and Uldarico AlmiranezTIME COMPLETED:
01:15 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver Conrad Caniga. LPA Quiroz called Licensee/Administrator (L/AD) Uldarico Almiranez and explained the nature of the visit. L/AD Almiranez arrived during today's visit.

Facility indicated screening all incoming visitors prior to entering the facility. This facility is licensed to provide services to age range 60 and over, approved for six (6) Non-Ambulatory Residents of which 1 (one) may be bedridden and has a hospice waiver for five (5) residents. Administrator (AD) Uldarico Almiranez has an Administrator Certificate with expiration date of April 10, 2024.

On or about 9:46am, LPA Rosie Quiroz along with Caregiver Caniga began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility at this time. During today's visit 3 of 3 interviewees indicated "There was Covid few weeks ago," LPA Quiroz reviewed COVID-19 share-point and COVID FAS entries, and verified there were no reported COVID-19 entries from this facility since commencement of COVID-19 Pandemic. At 10:26am, L/AD Almiranez indicated "It was on June 26, Resident 1 had covid, but it's been 2 years of this COVID stuff so I didn't feel it was important to notify you guys." (SEE LIC 809-D)

At 9:50am, LPA Quiroz observed cabinet between kitchen and livingroom area opened. LPA Quiroz inquired what was stored in that cabinet. Caregiver Caniga indicated "Oh the medications but it's supposed to be locked." This was verified with Caregiver Caniga (SEE LIC 809-D)

During today's inspection tour, LPA Quiroz observed four of six residents in their bedroom resting, two of six residents were observed walking throughout facility in living room area. LPA Quiroz interacted and interviewed with resident's during today's visit.

CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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 4


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
VISIT DATE: 08/25/2022
NARRATIVE
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 On or about 10:01am-10:12am, while conducting inspection tour of kitchen area and living-room area, LPA Quiroz observed unkept floor not kept free of debris, dust, dirt, what appeared to be pet hair, and what appeared to be food particles in between couches, on couches, and between refrigerator and cabinet drawers. This was verified with Caregiver Caniga and Licensee/Administrator Almiranez. (See LIC 809-D)
LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature in resident's bedrooms was recorded to be within normal limits.
On or about 10:17am- 10:30am, LPA Quiroz inspected resident's bedrooms and bathrooms. Water temperatures were recorded to be between 108.7-109.4 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. At 10:33am, based on interview conducted with interviewee, LPA Quiroz observed loose hand rails on toilet seat. This was verified with L/AD Almiranez at 10:30am, indicating "Yeah, I need to change that."
LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area backyard for residents and visitor's enjoyment in backyard area. LPA Quiroz was informed that six of six residents and staff have had their COVID-19 vaccinations.
During today's visit, while LPA Quiroz provided Consultation on Title 22 and ongoing COVID-19 Infection control and reviewing areas observed during today's visit, L/AD Almiranez began to raise his voice indicating "You're always looking for things and you come early when staff are still not done with their daily routine. It's been more than 2 years of COVID, and I didn't feel like I had to report it." LPA Quiroz explained duties of an LPA and reason for today's visit, L/AD Almiranez continued to raise his voice and behavior continued to escalate as evident of tone of voice and hand movements. On or about 10:39am, LPA Quiroz, excused herself and informed L/AD Almiranez that his behavior would be addressed with management and that a copy of today's report and deficiencies would be delivered at a later time after consulting with Management.
L/AD Uldarico Almiranez was not able to sign today's report and LIC 809-D pages, due to LPA Rosie Quiroz excusing herself from facility at 10:39am due to L/AD Uldarico's unprofessional behavior towards LPA Quiroz. LPA Quiroz drove to nearby Starbucks to type up report and delivered it to staff greeting at the door requesting to provide copy of today's report, LIC 811-Confidential names, LIC 809-D pages and Appeal Rights to L/AD Uldarico Almiranez. LPA Quiroz thanked Staff receiving report at facility door for their time.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/25/2022 12:59 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: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2022
Section Cited

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87211(a)(2)Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports...(2)Occurrences, such as epidemic outbreaks...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. CONTINUED BELOW
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This requirement was not met as evidenced by:3 of 3 interviewees indicated "There was Covid few weeks ago," LPA Quiroz reviewed COVID-19 share-point and COVID FAS entries, and verified there were no reported COVID-19 entries from this facility since
CONTINUED...
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commencement of COVID-19 Pandemic. At 10:26am, L/AD Almiranez indicated "It was on June 26, and it's been 2 years of this COVID stuff so I didn't feel it was important to notify you guys." This poses an immediate risk to residents in care.
Type A
08/26/2022
Section Cited

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Care of persons with Dementia: 87705(f)(2):(f)The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins...This requirement was not met as evidenced by:At 9:50am, LPA Quiroz observed... CONT BELOW...
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cabinet between kitchen and livingroom area opened. LPA Quiroz inquired what was stored in that cabinet. Caregiver Caniga indicated "Oh the medications but it's supposed to be locked." This was verified with Caregiver Caniga at 9:50am. This poses an immediate 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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/25/2022 12:59 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: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2022
Section Cited

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Maintenance and Operation 87303(a)(1): (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services...(1)Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. CONTINUED BELOW
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This requirement was not met as evidenced by: On or about 10:01am-10:12am, while conducting inspection tour of kitchen area and living-room area, LPA Quiroz observed unkept floor not kept free of debris, dust, dirt, what appeared to be pet hair, and what appeared to be food particles in between couches, on couches, and between... CONT
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refrigerator and cabinet drawers. This was verified with Caregiver Caniga and Licensee/Administrator Almiranez.
At 10:33am, LPA Quiroz observed loose hand rails on toilet seat. This was verified with L/AD Almiranez at 10:30am, indicating "Yeah, I need to change that." 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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
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