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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005475
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:17:37 PM


Document Has Been Signed on 02/27/2024 04:17 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 2FACILITY NUMBER:
306005475
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:17690 SAN VICENTETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
02/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:26 PM
MET WITH:Dolores Martillano, Caregiver and Uldarico Almiranez, Licensee/RepresentativeTIME COMPLETED:
04:18 PM
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This unannounced Case Management – Other inspection visit is being conducted by Licensing Program Analyst (LPA) Rosie Quiroz for the purpose of delivering amended findings for Complaint Control #22-AS-20220621095243 and Complaint control #22-AS-20230413150926 based on anonymous videos as evidence provided to the department.

LPA Quiroz was greeted by Caregiver 1 (CG1). LPA Quiroz called Licensee/Administrator (L/AD) Uldarico Almiranez and explained the purpose of the inspection visit. (L/AD) Almiranez arrived during today's visit.

During today's inspection visit, LPA Quiroz along with Caregiver toured the interior and exterior of facility premises. LPA Quiroz reviewed the previously delivered findings and the amended findings/reports with (L/AD) Almiranez.

An exit interview was conducted and copy of this report and the amended reports were provided to (L/AD) Almiranez at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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