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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005565
Report Date: 03/14/2022
Date Signed: 03/14/2022 01:31:38 PM


Document Has Been Signed on 03/14/2022 01:31 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:AK AND DAVID SENIOR CAREFACILITY NUMBER:
306005565
ADMINISTRATOR:CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:24302 BARK STTELEPHONE:
(949) 677-3394
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mary Jean CatacutanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by Priscila Pascual, caregiver and LPA explained the nature of the visit. Mary Jean Catacutan, Administrator arrived shortly after and met with LPA.

LPA Martinez accompanied by caregiver began the tour of the inside and outside of the facility. There are five residents in care and there is no active covid-19 case in the facility. LPA observed one resident in the living room watching TV and the remainder of the residents in their bedrooms. All residents appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperature daily and documenting the results. LPA observed posted in the wall of the dinning room the emergency disaster and evacuation plan. Facility has emergency food and water supply as well as PPE supplies. Facility has a second floor that is occupied by live in staff, there are no resident residing on the second floor and have no access to the second floor. LPA toured the outside of the facility and observed a shaded seating area for resident’s enjoyment. LPA was informed that residents and staff have received their covid-19 booster shot. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed and approved by the Department on April 10, 2021.

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 the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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