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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005475
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:27:05 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 SENIOR HOMES 2FACILITY NUMBER:
306005475
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:17690 SAN VICENTETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Rico Almiranez and Dolores MartillanoTIME COMPLETED:
04:01 PM
NARRATIVE
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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 by Caregiver Dolores Martillano and explained the reason for the visit. Administrator Rico Almiranez arrived during the visit.

At 1:20 PM, LPA toured the facility with Administrator Almiranez. Facility has 6 residents in care during today's visit. LPA observed residents relaxing in the facility. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer as well as hand washing signage. All rooms are single occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents results. LPA observed ample sanitizer spread out throughout the facility. Facility has covid precaution postings as well as all required department postings. Facility mitigation plan has been submitted and approved. LPA observed an ample supply of emergency food and water in the garage. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked. At 1:30 PM, LPA observed the medication storage area was unsecured. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six resident files during the visit and all contained updated emergency information. LPA observed three out of six residents are under the age of sixty. Residents 1, 3, and 4 are under the age of sixty thus outside of the conditions of the license. One out of six residents has bedridden status in the file. All residents and staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of following department recommended guidelines for covid precautions and visitation for residents.
Based on observations made during today's visit, the following deficiencies were cited based on Title 22,
Division 6, of the California Code of Regulations. An exit interview to review this report was conducted and a copy along with Appeal Rights, LIC 811- Confidential Names list, LIC 421C- Civil Penalty Assessment, and LIC 9102TA- Advisory Notes was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 3
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 2
FACILITY NUMBER: 306005475
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA observed Resident 2 has bedridden status deemed indefinite per physician report dated 06/23/2020. Facility does not have bedridden fire clearance. This poses an immediate health and safety risk to persons in care.
CIVIL PENALTY ASSESSED.
POC Due Date: 08/25/2021
Plan of Correction
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3
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Licensee to submit for a bedridden fire clearance and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(h)(2)



This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, the licensee did not comply with the section cited above. LPA observed medication cabinet is unsecured.. This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/25/2021
Plan of Correction
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Licensee secured items during visit. Cleared during visit.
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: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 2
FACILITY NUMBER: 306005475
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in three out of six residents who are under the age of sixty. Facility is operating outside of the license. This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/25/2021
Plan of Correction
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Licensee to submit an exception to retain the three residents who are under sixty to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3