306005475-8-24-2022-22-AS-RQUZ-CHLUSX-20220824155106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005475
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:51:42 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/24/2022 03:51 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:	FOUNTAIN VALLEY SENIOR HOMES 2		FACILITY NUMBER:	306005475
ADMINISTRATOR:	ALMIRANEZ, ULDARICO		FACILITY TYPE:	740
ADDRESS:	17690 SAN VICENTE		TELEPHONE:	(949) 290-6006
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	08/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:28 PM
MET WITH:	Dolores Martillano, Caregiver and Rico Alimiranez, Administrator		TIME COMPLETED:	04:01 PM

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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted, COVID-19 screened and granted entry into the facility by Caregiver Dolores Martillano. LPA Quiroz called Licensee/Administrator (L/AD) Uldarico Almiranez and explained the nature of the visit. L/AD Almiranez arrived during today's visit.

Facility indicated screening all incoming visitors prior to entering the facility. This facility is licensed to provide services to age range 60 and over, approved for six (6) Non-Ambulatory Residents and has a hospice waiver for five (5) residents. Facility is currently providing hospice services to (0) zero resident at this time. Administrator (AD) Uldarico Almiranez has an Administrator Certificate with expiration date of April 10, 2024.

On or about 2:50pm, LPA Rosie Quiroz along with caregiver Martillano began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed three of six residents in their bedroom resting, one of six residents in living room area watching television with staff supervision. Caregiver Martillano indicated "The other two residents are out of the facility. One is with his Family and the other one went to the bank." Four of four staff present during today's visit were observed to be wearing masks throughout today's visit.

LPA Quiroz interacted and interviewed with resident's during today's visit. Four of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature in resident's bedrooms was recorded to be within 76-79 degrees. LPA Quiroz observed wall air conditioners in six of six bedrooms.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

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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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
	VISIT DATE: 08/24/2022

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All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be between 105.7-107.2 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and kitchen area readily available for staff and residents.

LPA Quiroz toured the outside of the facility and observed seating and shaded area in front porch area, side area and backyard for residents and visitor's enjoyment in backyard area. LPA Quiroz was informed that six of six residents and staff have had their COVID-19 vaccinations and 2 boosters.

During today's visit, LPAs provided Consultation on Title 22 and ongoing COVID-19 Infection control and indoor facility temperature during hot weather season throughout today's visit. Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with (L/AD) Uldarico Almiranez and a copy of this report and LIC 811 Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

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