<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005464
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:27:42 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:FREEDOM MANOR, THEFACILITY NUMBER:
306005464
ADMINISTRATOR:MACH, MYLA GFACILITY TYPE:
740
ADDRESS:23672 CAVANAUGH ROADTELEPHONE:
(562) 536-8860
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Myla MachTIME COMPLETED:
03:28 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA signed in and completed a temperature check. LPA met with Administrator, Myla Mach, informed AD of the purpose of the visit, and conducted a tour of the inside and outside of the facility, common areas, kitchen, bedrooms, bathrooms, and garage.

LPA discussed and observed the following:

LPA observed Covid-19 station with sign in sheet, hand sanitizer, and disinfectant wipes. The facility also requires temperature checks for all visitors and staff. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed PPE and hygiene products in the garage. Hallways and walkways were free from obstruction. LPA discussed Covid-19 Mitigation Plan and reviewed Covid-19 temperature log for staff and residents. LPA discussed updated Covid-19 requirements including surveillance testing, signage, PPE requirements, and Covid-19 reporting requirements. LPA discussed PIN 21-40 ASC: Updated Statewide Visitation, Waiver, and Testing and Vaccination Verification Guidance for Visitors Related to Coronavirus Disease 2019 (Covid-19).

No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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 1