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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005464
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:46:56 PM


Document Has Been Signed on 07/12/2022 03:46 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: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:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Lucena Er-ErTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Myla Mach and House Manager Yolanda Ramirez arrived during the visit.

At 1:45 PM, LPA toured the facility with Caregiver Lucena Er-Er. House Manager Yolanda Ramirez and Administrator Myla Mach joined the tour in progress. Facility is a two story home with the second floor reserved for care staff. Facility has 6 residents in care during today's visit with 2 residents on hospice care. LPA 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. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet/ questionnaire. Facility takes resident and staff temperatures daily and documents. LPA observed the first aid kit has all required items. Facility has completed the infection control plan and plan to be submitted to licensing. LPA observed an ample supply of emergency food and water. Smoke detectors tested operational during today's visit and fire extinguisher is mounted and charged. LPA observed the shaded outside visitation area. Exit gates are self latching and unlocked. LPA observed the locked medication area. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files have updated emergency information as well as required documents. All residents and staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of updating physician reports for all residents and ensuring full bed rails are only utilized for hospice residents per physician order. Additionally, LPA consulted on posting the "The Let Us No" poster in the entrance of facility in regulation size, "20 X 26."

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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