306005796-9-16-2022-22-AS-ETAA-CJBRL6-20220916130638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005796
Report Date: 09/16/2022
Date Signed: 09/16/2022 01:06:45 PM

Document Has Been Signed on 09/16/2022 01:06 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:	ACTIVCARE ORANGE		FACILITY NUMBER:	306005796
ADMINISTRATOR:	LEDESMA, ELVA		FACILITY TYPE:	740
ADDRESS:	2629 E. CHAPMAN AVENUE		TELEPHONE:	(714) 215-9944
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	72	CENSUS: 14	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Elva Ledesma, Luciano DeLeon		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Director Quality Assurance Elva Ledesma and Family Advisor Luciano Deleon and stated the purpose of this visit. The facility is a single-level structure divided into four wings and licensed for seventy-two non-ambulatory residents of which seventeen may be bedridden and fifteen may be on hospice. This facility offers Residential Care for the Elderly/Dementia. At about 11:25 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. Resident rooms were selected at random for inspection. Rooms that were selected for inspection were (202,204,205,303). Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident rooms had shared of restrooms. Resident restrooms were observed to be in good repair and provided with grab bars and hot water was measured between 105.8 degrees and 110.6 degrees Fahrenheit. LPA also notice handing washing signs throughout the facility. LPA Tapia notice PUB 475 posters posted in prominently locations. LPA was provided a report for smoke detectors and carbon monoxide alarms being tested on 07/14/2022. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed to be charged and operational. For the exterior portion, facility had an outside patio with furniture in good repair; and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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: ACTIVCARE ORANGE	FACILITY NUMBER: 306005796
	VISIT DATE: 09/16/2022

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Kitchen was in good repair and in a separate room inaccessible to residents. Dining room was in good repair and seating arrangements are 2 persons per table. Facility also had a medication, maintenance, and laundry room all of which were in good repair. LPA Tapia reviewed the COVID 19 mitigation plan and Emergency Disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No advisory was issued today.

LPA Tapia conducted an exit interview with Director Quality Assurance Elva Ledesma and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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