306005796-8-24-2020-22-AS-RQUZ-BSSV33-20200824160405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005796
Report Date: 08/24/2020
Date Signed: 08/24/2020 04:04:20 PM

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:	ACTIVCARE ORANGE		FACILITY NUMBER:	306005796
ADMINISTRATOR:	SHETTER, TODD A.		FACILITY TYPE:	740
ADDRESS:	2629 E. CHAPMAN AVENUE		TELEPHONE:	(858) 565-4424
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	72	CENSUS: 0	DATE:	08/24/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Todd Shetter, Licensee and Elva Ledesma, Administrator		TIME COMPLETED:	01:52 PM

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Licensing Program Analyst (LPA) Rosie Quiroz conducted an announced Pre-Licensing visit with Component III Orientation via phone Face-Time virtual technology to Activcare Orange due to the Coronavirus Pandemic and precautionary measures. LPA Quiroz conducted the visit with Licensee Todd Shetter and Administrator Elva Ledesma. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/31/2020 for a capacity of 72 residents; of which 55 may be Non-Ambulatory residents and 17 may be bedridden residents. Facility has a hospice waiver for 17 residents.

On or about 10:22am, LPA Quiroz along with Licensee Todd Shetter and Administrator Elva Ledesma began the virtual pre-licensing inspection and observed the following:

Structure:

Facility is a one story building composed of 4 wings. The one-hundred wing referred to as "Old Town Orange" will house higher functioning residents. The two hundred and three hundred wing referred to as "Baseball Alley" will house mid to moderate needs residents. The four hundred wing referred to as "Patriotic American wing" will house bedridden and hospice residents. There are two secured courtyards that offer a putty green area and ample shade and outdoor seating to accommodate residents and visitors. The court yard in the "Old Town Orange" wing includes a golf area for residents.
Signal System:
The facility's central heating and air conditioning is controlled by a thermostat located in each corridor. Each corridor has two to three thermostats. The indoor temperature was recorded to be 71 degrees Fahrenheit. Functional and Operational central heating and air conditioner.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020

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: ACTIVCARE ORANGE	FACILITY NUMBER: 306005796
	VISIT DATE: 08/24/2020

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Bedrooms for Residents:
The resident bedrooms accommodate residents' furnishings such as a bed, lamp, night stand, dresser drawers and a closet.
Bathrooms:
Resident bathrooms have a working toilet, wash basin, and shower area. Non-skid surface mats were present during virtual inspection tour.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were present and stored in a laundry room area and in linen closet in each corridor.
Emergency Phone Numbers, Exit Plan:
The emergency disaster plan, facility sketch and exit plan were posted in the facility towards facility entrance area in main lobby and in each corridor. Functional and operational facility phone available in the facility.
Postings:
The let us know poster was present and posted in the entry way of the facility. Coronavirus (COVID-19) postings were posted through out the facility in designated areas due to precautionary measures.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review. Emergency food supplies were noted to be available at the facility.
At 11:05am, LPA Quiroz observed 5 emergency stoves and butane fuel for stoves in an event of an emergency.
Smoke and Carbon Monoxide Detectors:
Smoke detector alert systems were tested and found operational. The carbon monoxide detector was tested and found to be operational. Carbon Monoxide detectors located in each resident bedroom and corridors.
Fire Extinguisher:
There are 9 Fully charged fire extinguishers located throughout the facility. Fire extinguishers were last serviced on 4/2/2020.
Fire Clearance:
Approved on 07/20/2020 for a capacity of 72 residents of which 55 may be non-ambulatory and 17 may be bedridden. Hospice waiver for 17 residents.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020

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: ACTIVCARE ORANGE	FACILITY NUMBER: 306005796
	VISIT DATE: 08/24/2020

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Appliances/Kitchen and Laundry area: Gas burner stove, one large commercial oven split in two ovens, walk in refrigerator and two stand alone units/walk in freezer, and one microwave. one commercial washer, one commercial dryer, one retail washer, and one retail dryer are clean and noted to be operational in the laundry room.
Toxins:
Locked and stored in secured maintenance shop room.
Water Temperature:
Licensee Todd Shetter provided LPA Quiroz with the follow water temperature recordings measured on today's date: Room 101 recorded at 113.5 degrees F, Room 111 recorded at 112.8 degrees F, Room 201 recorded at 112.7 degrees F, Room 301 recorded at 112.8 degrees F, Room 311 recorded at 112.9 degrees F, Room 401 recorded at 112.7 degrees F, Room 411 recorded at 113.5 degrees F.
Medications, First Aid Kit & Manual:
There are five First Aid kits with guide is stored in medication room, maintenance shop, kitchen and program Director office area . Medication stored in a locked cabinet located in the medication room.
Resident and Staff Files:
Resident records are kept in a secured room located in the Nurses office. Staff files are kept in the Administrator Lobby area locked and secured.
Reading Material, Games, Equipment, & Materials:
The facility has activities that commensurate with their plan of operation. LPA Quiroz observed activity calendars posted in the facility. Facility subscribes with local newspaper and magazine companies.
Facility offers the following board games and activities: puzzles, board games, arts and crafts, bowling, and various activities offered in putty green area in the courtyards.

Quarantine Area: LPA Quiroz observed quarantine rooms available at the end of corridor in "Base ball Alley" wing. Licensee reported "There are a total of 8 beds to accommodate residents who require quarantine. The plan is to conduct a covid-19 test 48 hours prior to move in, and conduct a second covid-19 test on Day 8 or Day 9, and upon successful negative results, the resident can be transferred out of Quarantine area.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020

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: ACTIVCARE ORANGE	FACILITY NUMBER: 306005796
	VISIT DATE: 08/24/2020

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Administrator Elva Ledesma and Licensee Todd Shetter were reminded of the statute that requires them to notify Rosie Quiroz, Licensing Program Analyst at (559) 753-4610 within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax. LPA Rosie Quiroz provided Licensee David Chase and Administrator Sarah Paul with business card to facilitate communication with LPA Quiroz.

During the pre-licensing visit, LPA Quiroz informed Licensee and Administrator that Community Care Licensing Division (CCLD) is currently working to prevent the spread of the COVID-19 (corona virus). LPA Quiroz explained to both Licensee and Administrator the steps that CCLD is taking on COVID-19 (corona virus). LPA Quiroz also encouraged both Licensee and Administrator to visit the California Department of Public Health at https://www.cdph.ca.gov/ for more information.

LPA Quiroz conducted Component III orientation with Licensee Todd Shetter and Administrator Elva Ledesma. LPA Quiroz answered all questions asked.

Applicants satisfied all requirements in accordance with Title 22, California Code of Regulations and the facility physical plan meets requirement of Title 22. The facility is ready for licensure and the License will be granted upon approval by the Central Application Bureau (CAB). An exit interview was conducted with Licensee Todd Shetter and Administrator Elva Ledesma, and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020

LIC809 (FAS) - (06/04)

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