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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005719
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:09:06 PM


Document Has Been Signed on 03/14/2022 12:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:TRUCARE BOARDING HOME INC.FACILITY NUMBER:
306005719
ADMINISTRATOR:QUY, NATHANFACILITY TYPE:
740
ADDRESS:9367 SISKIN AVETELEPHONE:
(626) 382-9357
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Elena Chavez and Alex Chavez TIME COMPLETED:
12:16 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA observed all required postings on the wall throughout the facility. Administrator Mark Ryan P. Cruz has a current administrators certificate that expires on 12/02/2022. LPA was screened and temperature checked before entering the facility. LPA observed a screening log book, and temperature thermometer for screening clients and visitors. LPA began the tour with the facility staff. There were six residents in care at the facility. All client rooms and bathrooms were clean and well organized. Client rooms have the necessary requirements, night stand, chair, lamp and storage space. There was first aid supplies locked in a hallway closet. Bathrooms were operational and clean. In all bathrooms there were warning signs that them maximum water temperature is above 125 degrees F. The facility had a two day supply of perishable food items and seven days supply of nonperishable food items. The stove was clean and all four burners were operational. Knives were locked in a drawer in the kitchen. All hazardous chemical are locked below the sink. The facility has adequate PPE. LPA observed extra linen, emergency food and water supply. The garage area was clean and free of clutter. LPA observed additional water and food in the garage. LPA toured the backyard and observed an exit gate on the side of the house that was self closing and self latching. LPA observed a shaded patio area in the backyard with a table and chairs for the residents in care. All exit doors were tested, and the auditory exit alarms were operational. Smoke detectors were tested and were operational. No deficiencies are being cited during todays visit. After the inspection, an applicant in the process of being the new licensee arrived at the facility. His name is Reiner Avendano, and he stated there is a change or ownership in process. An exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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