306005574-6-1-2021-22-AS-SFRK-C3KKPY-20210601080532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005574
Report Date: 05/24/2021
Date Signed: 06/01/2021 08:05:40 AM

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:	EUROPEAN RETIREMENT LIVING LLC		FACILITY NUMBER:	306005574
ADMINISTRATOR:	TATARICI, FLORELA GABRIELA		FACILITY TYPE:	740
ADDRESS:	2689 CANARY DR		TELEPHONE:	(949) 394-5764
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 4	DATE:	05/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Florela Tatarici, Administrator		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Shobhana Frank arrived conducted an announced annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. LPA toured the facility inside and outside. Facility is a two story structure which has the capacity of retaining 6 residents. The licensee residences on the second floor of the structure and the facility is located on the first floor of the structure. This facility has 4 bedrooms 2 private bedrooms and 2 share bedrooms. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, visitors log. LPA observed Covid posters throughout the facility. LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational Requirements. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 109.9 degrees F. Grab bars, non-slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Reviewed Mitigation plan – LIC 808 –Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services (Department) all items meet the required components. On May 18, 2021 facility conducted surveillance Testing and results are negative. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed two resident records. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. Dementia and hospice regulation requirements are being met.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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: EUROPEAN RETIREMENT LIVING LLC	FACILITY NUMBER: 306005574
	VISIT DATE: 05/24/2021

NARRATIVE

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Personnel Records/Training/and Staffing- LPA reviewed two employee records. CPR and annual training requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the residents in care. The facility administrator is present a sufficient number of hours to maintain the facility. Administrator certification is present.

Food Service- LPA observed meal being served. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair.

Fire extinguishers are charged, mounted and dated 04/16/2021. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. The facility does not handle resident money.

two client interviews were conducted.

Based on the information received during this visit today, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC809 (FAS) - (06/04)

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