306005796-9-18-2024-22-AS-ARJR-D98RQN-20240918131346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005796
Report Date: 09/18/2024
Date Signed: 09/18/2024 01:14:12 PM

Document Has Been Signed on 09/18/2024 01:14 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:	ACTIVCARE ORANGE		FACILITY NUMBER:	306005796
ADMINISTRATOR:	VANESSA VALENCIA		FACILITY TYPE:	740
ADDRESS:	2629 E. CHAPMAN AVENUE		TELEPHONE:	(714) 215-9944
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	72	CENSUS: 38	DATE:	09/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Brianna Salgado-Receptionist, Vanessa Valencia-Administrator		TIME COMPLETED:	01:24 PM

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On this day, Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry to facility by Receptionist Brianna Salgado. Administrator (AD) Vanessa Valencia arrived shortly after.

LPA Ramirez toured the interior and exterior portions of the facility with Maintenance Director Jonathan Sotomayor. During this visit, there are a total of 18 staff members on duty. The facility is a single level structure and is licensed for 72 non-ambulatory residents, of which 15 may be on hospice and 17 may be bedridden. Currently, there are a total census of 38 residents in care. LPA Ramirez initiated random bedroom checks, of which bedrooms were observed to have furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be between 105.8-108.6 degrees Fahrenheit.

Smoke and carbon monoxide detectors were operational and the most recent fire inspection took place on August 28, 2024, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA Ramirez also tested pull cords in resident bedrooms, and observed to be operational.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. LPA toured the kitchen and observed the weekly food menu. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility.

CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACTIVCARE ORANGE	FACILITY NUMBER: 306005796
	VISIT DATE: 09/18/2024

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For the exterior portion, LPA Ramirez observed patio furniture under shading, and the grounds were free of any hazards. LPA observed the emergency disaster and evacuation plan, which is posted at the main entrance by the front desk.

LPA Ramirez observed that First Aid Kit had all the required components. Medications were locked and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents.

During the tour LPA observed the residents participating in a History class.

LPA reviewed five resident files and five staff files.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA Ramirez advised BOM Belanger to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA Ramirez conducted an exit interview with AD Valencia and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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