306005796-9-29-2021-22-AS-RQUZ-C7BQ8N-20210929115703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005796
Report Date: 09/29/2021
Date Signed: 09/29/2021 11:57:09 AM

COMPREHENSIVE INSPECTION

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:	LEDESMA, ELVA		FACILITY TYPE:	740
ADDRESS:	2629 E. CHAPMAN AVENUE		TELEPHONE:	(858) 565-4424
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	72	CENSUS: 12	DATE:	09/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Elva Ledesma, Administrator		TIME COMPLETED:	11:58 AM

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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 and granted entry into the facility by Front desk Receptionist and met with Executive Director (ED) ED Elva Ledesma, and explained the nature of the visit. This facility is licensed to provide services to Dementia Residents, age range 60 and over, and approved for seventy-two (72) Non-Ambulatory Residents, of which seventeen (17) may be bedridden and has a hospice waiver for fifteen(15) residents. This facility is approved for secured perimeter egress. ED Elva Ledesma has an Administrator Certificate with expiration date of 10/7/2021 .

On or about 10:53am LPA Quiroz along with ED Ledesma toured the inside and outside of facility. All staff working at facility were observed to be wearing face masks upon arrival to facility. There are twelve (12) residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed residents participating in Yoga excercise activity and making Birthday hats . Residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary with all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment. Facility has completed the LIC 808 Mitigation plan, which was approved by LPA Micah Martinez on 2/9/2021.

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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: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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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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: 09/29/2021

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During today's inspection visit, LPA Quiroz reviewed five of twelve resident records.

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.

This report was reviewed with ED Elva Ledesma, and a copy of this report was provided to ED Ledesma at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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