306005600-5-6-2022-22-AS-PVEZ-CE6PPS-20220506113002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005600
Report Date: 05/06/2022
Date Signed: 05/06/2022 11:30:06 AM

Document Has Been Signed on 05/06/2022 11:30 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:	COUNTRY GARDENS TERRACE		FACILITY NUMBER:	306005600
ADMINISTRATOR:	DIZON, BENJIE		FACILITY TYPE:	740
ADDRESS:	1103 SALVADOR STREET		TELEPHONE:	7145570515
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 5	DATE:	05/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Teresita Calso - Caregiver		TIME COMPLETED:	11:45 AM

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) Patricia Velazquez conducted an unannounced visit to Country Gardens Terrace. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Normelyn Torres. Caregiver Teresita Calso was also present. The facility is licensed for 6 non-ambulatory residents. The facility also has a Hospice waiver for 3 residents. There are currently 5 residents living in the facility. The facility staff did not know when the last emergency disaster drill was conducted. At 10:14 AM LPA Velazquez conducted a tour of the physical plant along with CG Calso. The 1 story home consists of 6 resident bedrooms with 6 bathrooms. There is 1 staff bedroom. The facility also has a living room, dining area, and kitchen. The 5 residents in the facility appeared well-groomed and well cared-for. LPA Velazquez observed the Complaint Poster was not in the correct size and advised CG Calso to obtain one in the correct size of 20" by 26". The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 109.9 degrees Fahrenheit in the first bathroom, at 110.9 in the left sink and at 111.5 degrees Fahrenheit in the right sink of the second bathroom, at 109.5 degrees Fahrenheit in the third bathroom, at 102.5 degrees Fahrenheit in the fourth bathroom, at 107.6 degrees Fahrenheit in the fifth bathroom, and at 110.9 degrees Fahrenheit in the left sink and at 111.5 degrees Fahrenheit in the right sink of the sixth bathroom.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
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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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: COUNTRY GARDENS TERRACE	FACILITY NUMBER: 306005600
	VISIT DATE: 05/06/2022

NARRATIVE

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LPA Velazquez inspected the kitchen along with CG Calso. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition.

LPA Velazquez along with CG Calso toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and one of the 2 the exit gates did not have a self-closing latch. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit.

There were no deficiencies issued during this 1 Year inspection. An exit interview was conducted with Caregivers Teresita Calso and Normelyn Torres and a copy of this report along with the LIC 9102s were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
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

LIC809 (FAS) - (06/04)

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