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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005754
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:00:52 PM


Document Has Been Signed on 05/05/2022 03:00 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:MILES PLACE OF FOUNTAIN VALLEYFACILITY NUMBER:
306005754
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:18667 SAN FELIPE STREETTELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Mark Cruz, Administrator and Analyn TanagonanTIME COMPLETED:
03:05 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Live in Caregiver (LCGL) Analyn Tanagonan. LPA Rosie Quiroz explained the nature of the visit to (LCG) Analyn Tanagonan. Administrator (AD) Mark Ryan Cruz arrived shortly after. (AD) Mark Cruz has an Administrator certificate with expiration date of 12/2/2022. Licensee/Administrator Reiner Avendano has an Administrator certificate with expiration date of 10/6/2022. Facility indicated screening all incoming visitors prior to entering the facility.
On or about 1:27pm, LPA Rosie Quiroz along with (LCG) Tanagonan began the tour of the inside and outside of the facility. There are six residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed three of six residents in living room area resting and watching television and three of six residents in their own bedroom resting. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility.
All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 106.0-106.9 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan at facility entrance. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for resident and visitor's enjoyment. The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 22, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated June 22, 2021. LPA Quiroz was informed that all residents have had their COVID-19 vaccinations and Boosters, staff scheduled for first booster on May 2022, and resident's scheduled for second booster on June 2022. Facility is recording resident's temperatures daily, and indicated they well "start recording resident's temperatures two times per day in the morning and at bedtime."Continued on next page...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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: MILES PLACE OF FOUNTAIN VALLEY
FACILITY NUMBER: 306005754
VISIT DATE: 05/05/2022
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Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22, COVID-19 Mitigation and Infection control throughout today's visit.

This report was reviewed with (AD) Mark Cruz, and a copy of this report and LIC 811 Confidential Names were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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