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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005599
Report Date: 05/06/2022
Date Signed: 05/06/2022 11:08:02 AM


Document Has Been Signed on 05/06/2022 11:08 AM - 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:A1 ELDER CAREFACILITY NUMBER:
306005599
ADMINISTRATOR:SHAH, BINDIFACILITY TYPE:
740
ADDRESS:2538 E LARKSTONE DRIVE #ATELEPHONE:
(949) 929-5318
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Leticia SolisTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Leticia Solis and Arlene Molina. Administrator Bindi Shah was spoken to via telephone. The focus of the visit was Infection Control. LPA toured the facility with Ms. Solis and the following was observed:

Covid signs were posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Administrator Certificate for Bindi Shah expires on 6/27/23 . Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. The swimming pool meets Title 22 regulation at this time. Residents were resting in their rooms and others watching tv. Social distancing and masks for staff were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication closet for resident medication and files. All residents have at least a 30 day supply of medications.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and hand washing for staff. Administrator is reminded to review PINS in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as Staff Testing and Masking Guidelines. All staff have had vaccines and the booster shot. All residents but 1 have received vaccines. Only 1 resident has had the booster. An exit interview was conducted and a copy of this report was provided to Staff Leticia Solis.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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