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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005497
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:19:39 PM

Document Has Been Signed on 03/02/2022 03:19 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:ANKERTON SUITEFACILITY NUMBER:
306005497
ADMINISTRATOR:ANGELES, OFELIAFACILITY TYPE:
740
ADDRESS:24192 ANKERTON DRIVETELEPHONE:
(714) 553-6849
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager Eric EsquerraTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. LPA met with House Manager (HM) Eric Esguerra and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden and hospice waiver for six. For this visit, there was one resident under hospice care.

About 2:00 PM , LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were four residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were six private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid-floor mat. Hot water was measured at 113 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. LPA observed personal protective equipment in place. For the exterior portion, facility had outside furniture in good repair. Side exit doors were self latching and self closing. LPA Marin reviewed the COVID 19 mitigation plan of the facility.

LPA Marin did consultation and assisted HM Esguerra with the Guardian system. HM will use the link https://cdss.ca.gov/inforesources/community-care/caregiver-background-check from the Department website.

LPA Marin advised to send all incident reports and general correspondence to Community Care Licensing Division Orange Office using the email: CCLASCPOrangeCountyRO@dss.ca.gov

No citation was issued during this visit.

LPA Marin conducted an exit interview with HM Esguerra and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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