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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005475
Report Date: 08/30/2021
Date Signed: 08/30/2021 02:43:46 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:
08/30/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rico Almiranez, Administrator, Alisa Ortiz, Licensing Program Manager, Rosie Quiroz, Licensing Program AnalystTIME COMPLETED:
11:51 AM
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An informal virtual meeting was held on Microsoft teams due to Covid 19 restrictions and precautionary measures. The purpose of today's meeting was to discuss recent un-announced visit conducted on 8/24/2021 and facility visitation policy.

Present during today's meeting were Licensing Program Manager (LPM) Alisa Ortiz, Licensing Program Analyst (LPA) Rosie Quiroz and Administrator Rico Almiranez.

The following items were discussed:


-COVID 19 Guidelines
-Ambulatory status on physician reports
-Facilities responsibility in review of resident's records
-Latest updates regarding: PIN 21-40 ASC
-Appeal Rights
Administrator explained recent COVID-19 facility visitation guidelines and reported that he is allowing on site visitations with COVID-19 screenings and all precautionary measures. Administrator agreed to review the latest PIN 21-40 ASC provided by LPA Quiroz via email on today's date. Administrator Almiranez understands it is the facilities responsibility to review resident records for compliance.

An exit interview was conducted with Administrator Almiranez via telephone and a copy of this report was provided to Administrator Almiranez via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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