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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005463
Report Date: 10/27/2021
Date Signed: 10/27/2021 04:44:51 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:FOUNTAIN VALLEY SWEET HOMEFACILITY NUMBER:
306005463
ADMINISTRATOR:NGUYEN, MAI TFACILITY TYPE:
740
ADDRESS:10171 NORTHHAMPTON AVETELEPHONE:
(714) 867-8074
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 5DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Licensee Mai NguyenTIME COMPLETED:
03:09 PM
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility today to conduct required 1 year inspection. During today’s visit, LPA met with Licensee Mai Nguyen and explain the purpose of today's visit. LPA Frank toured the facility, inspected resident rooms and bathrooms, reviewed staff training records. LPA Frank reviewed centrally stored medications and records, reviewed food services, and inspected the kitchen.
In addition, LPA Frank tested the hot water temperature, which measured 108.4 degrees F in resident
bathroom. Resident areas were noted to be a comfortable temperature.
Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility also
has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply: 2 day supply of
perishables and 7 day supply of non-perishable food is available for the number of residents present.
Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA
observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet.
LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log,
COVID posters throughout the facility. LPA observe the facility to be clean and in good repair.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808) Mitigation Plan; 3) Current Liability Insurance, 4) Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500).
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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