306005717-4-13-2022-22-AS-SFRK-CDFPPB-20220413112917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005717
Report Date: 04/12/2022
Date Signed: 04/13/2022 11:30:25 AM

Document Has Been Signed on 04/13/2022 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:	LEISURE LOVE HOME CARE		FACILITY NUMBER:	306005717
ADMINISTRATOR:	DELA CRUZ, DENNIS S		FACILITY TYPE:	740
ADDRESS:	24362 FORDVIEW		TELEPHONE:	(949) 454-1623
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	04/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Licensee Dennis Dela Cruz		TIME COMPLETED:	03:10 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 conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Licensee Denis Dela Cruz and explained the reason for the visit. LPA Frank toured the facility. There are 6 residents residing in the facility and no active COVID-19 cases. LPA observed 6 residents on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking residents temperatures and documenting results. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. In addition, LPA Frank tested the hot water temperature, which measured 106.3 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility also has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply: 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet. LPA observe the facility to be clean and in good repair. LPA inspected the overall physical plant for any obstruction or safety hazards that can cause the health and safety of the residents. No camera installed observed during the visit . LPA verified if facility is providing a comfortable temperature due to hot/cold weather condition. Facility has a working centralized heater to use for the cold weather and centralized air condition and fans for the hot weather. During the visit the facility air condition is on and operational.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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: LEISURE LOVE HOME CARE	FACILITY NUMBER: 306005717
	VISIT DATE: 04/12/2022

NARRATIVE

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LPA reviewed : 1.) Emergency Disaster Plan (LIC610E) LPA also discussed about emergency disaster plan procedures for other calamities as an addition to existing emergency procedures that the facility have on file. (LIC 808) Mitigation Plan and Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500)
LPA reviewed staff records; LIC 500 reviewed. LPA observed staff work schedule indicates administrator on premises 40 hours per week. There are no excluded persons employed by this facility upon review of CCL current personnel list.
LPA reviewed current Administrator Certificate that expires on 6/20/2022. All staff first aid card were reviewed and current. Staff training's reviewed. Staff medical assessment reviewed. LPA also answer some questions and inquiries during the visit and verified information of records being reviewed.

LPA reviewed two residents files. The following records were reviewed: Medications and records, Admission agreement, Physician's reports and individual services plan is available and updated for the residents. LPA reviewed resident's activities being provided by the facility. Dementia safeguards were inspected and auditory devices were tested on exit doors.
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected. This report was discussed with the facility representative and a copy was provided.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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