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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005755
Report Date: 06/14/2021
Date Signed: 06/28/2021 11:52:50 AM

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:SACRED HEART SENIOR CAREFACILITY NUMBER:
306005755
ADMINISTRATOR:ALDIANO, ANNA LIZAFACILITY TYPE:
740
ADDRESS:25602 WILLOW BENDTELEPHONE:
(949) 600-7009
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marebith LupibaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to facility to conduct an Annual visit. Upon arrival LPA met with Staff Marebith Lupiba and discussed the purpose of visit. Staff Yvette Mendoza and Ditas Almendrala were also present. Administrator Anna Liza Aldiano was contacted by staff. She was not able to come to the facility.

During the visit LPA toured the facility inside and out with. LPA observed Covid signs at front entrance of facility as well as a sanitizing station. Facility has required Department postings throughout facility. LPA observed a copy of Administrators Certificate expiring 4/22/21 for Anna Liza Aldiano. LPA toured all resident rooms. All rooms were clean and sanitary. All restrooms observed contained ample supplies of hand sanitizer, soap, wipes, gloves and paper towels. LPA observed outside visitation areas with ample shading. Residents were observed watching tv, resting and completing a puzzle. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with facility staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff at all times.

No deficiencies noted during visit. An exit interview was conducted with Staff Marebith Lupiba and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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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