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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005520
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:07:52 PM

Document Has Been Signed on 10/26/2023 03:07 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BUENA VISTA HOMEFACILITY NUMBER:
306005520
ADMINISTRATOR:TUASON, LIEZLFACILITY TYPE:
734
ADDRESS:17777 BUENA VISTATELEPHONE:
(714) 983-7277
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 5CENSUS: 5DATE:
10/26/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Sebastian Flor - LVNTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr returned to the facility for the purposes of completing a plan of corrections visit. LPA was greeted and granted entry by LVN Sebastian Flor. LPA observed residents relaxing in living room. One resident was noted to be in the hospital.

LPA stated that they are following up on the following deficiency from the previous visit:

"Based on observations, the licensee did not comply with the section cited above as two of the three bathrooms had hot water temperatures below 105 degrees Fahrenheit which poses a potential safety risk to persons in care. Licensee stated to LPA that their lease agreement prevents facility staff from adjusting the water heater. LPA waited approximately 45 minutes after the initial measurement to measure the water again. The water still measured below 105 degrees Fahrenheit."

Upon testing the water in the two hallway bathrooms during today's visit, LPA determined the following:

Hot water in the bathroom closer the front of the house measured at 118.2 degrees Fahrenheit and hot water in the bathroom closer to the back of the house measured at 118.4 degrees Fahrenheit.

Based on hot water temperatures, LPA determined that the facility completed the plan of corrections before the assigned due date of 10/27/2023. A copy of the evaluation form was provided. A clear letter has been generated and provided to the facility as well.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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