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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005717
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:26:04 PM


Document Has Been Signed on 04/11/2024 02:26 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LEISURE LOVE HOME CAREFACILITY NUMBER:
306005717
ADMINISTRATOR:DELA CRUZ, DENNIS SFACILITY TYPE:
740
ADDRESS:24362 FORDVIEWTELEPHONE:
(949) 454-1623
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Facility Administrator - Dennie Dela CruzTIME COMPLETED:
02:41 PM
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Licensing Program Analysts (LPAs) Celine De Perio and Faith La conducted an unannounced required annual inspection. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty and facility administrator (AD) Denis Dela Cruz. The PUB475 "See Something, Say Something" poster was observed to be at the entrance of the facility. LPAs observed the Administrator's Certificate for Denis Dela Cruz, which expired on 1/18/24, however provided proof to LPAs that a payment was made to obtain the renewed certificate and that certificate is pending.

LPAs toured the interior and exterior portions of the facility with AD Dela Cruz. The facility is a two level structure and is licensed for 6 non-ambulatory residents, of which 0 may be bedridden and 4 may be on hospice. For this visit, there are a total of 4 residents in care, of which none are on hospice. On the first floor, there are a total of 3 shared resident rooms. On the second floor, there are 2 bedrooms, which are only designated for staff. LPAs verified that there are no residents residing on the second floor. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which 2 are for residents on the first floor, and 1 is for staff on the second floor. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 107.0 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care, and located in a kitchen drawer. Fire extinguisher was charged, mounted and located in the kitchen.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LEISURE LOVE HOME CARE
FACILITY NUMBER: 306005717
VISIT DATE: 04/11/2024
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LPAs observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the kitchen and in the garage. LPA De Perio observed that First Aid Kit had all the required components. Medications and toxins were observed to be locked and inaccessible to residents in care

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. LPAs observed an empty pool in the backyard, that is locked by a gate, and is made inaccessible to residents in care.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with AD Dela Cruz.

A copy of this report was explained and provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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