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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005767
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:07:11 PM


Document Has Been Signed on 08/12/2024 01:07 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:TRANQUILITY SENIOR LIVINGFACILITY NUMBER:
306005767
ADMINISTRATOR:BRYANT II, LANCEFACILITY TYPE:
740
ADDRESS:285 E 22ND STTELEPHONE:
(949) 331-2744
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Lance BryantTIME COMPLETED:
01:15 PM
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On 8/12/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Caregiver, Rosemarie Tarun who was informed of the purpose of LPA's visit. Administrator, Lance Bryant arrived during the visit and was also informed of the purpose of the visit. The facility has a fire clearance for six (6) bedridden elderly residents and an approved hospice waiver for six (6). LPA was informed two (2) residents are currently receiving hospice services at the facility. During today's visit, there was four (4) residents and three (3) staff present.

LPA toured the facility with Administrator, Lance Bryant and observed the facility is made up of a one-story home with six (6) resident bedrooms, seven (7) bathrooms, two (2) staff rooms, a kitchen, staff office, dining room, living room, and attached garage. During the tour, Caregiver, Darwin Maranan tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. The facility also has emergency food and water stored in the garage. There were no bodies of water observed on the premises. Medications are secured in a locked dining room cabinet. Each resident bedroom had their own bathroom. Resident bathrooms had grab bars near the toilet and in the showers along with non-skid mats built in the shower floors. The facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident files reviewed had signed admission agreements and physician reports. Staff present have a criminal record clearance and valid first aid/CPR certification. LPA called the facility's landline and observed it was operational. Complaint procedures, facility sketch, resident rights and emergency contact information are posted near the front entrance. Long Term Care Ombudsman information is posted in the living room.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Lead Caregiver, Rhea Gagabo-An.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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