306005806-8-14-2020-22-AS-PVEZ-BSGQC9-20200814120246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005806
Report Date: 08/14/2020
Date Signed: 08/14/2020 12:02:58 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:	WE CARE SENIOR LIVING		FACILITY NUMBER:	306005806
ADMINISTRATOR:	SANSANO, CHERRYL		FACILITY TYPE:	740
ADDRESS:	24322 BARK ST		TELEPHONE:	(949) 446-9841
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	08/14/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cheryl Sansano - Administrator		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an announced Pre-Licensing visit with Component III Orientation via phone FaceTime virtual technology to We Care Senior Living due to the Coronavirus Pandemic and precautionary measures. LPA Velazquez conducted the visit with Administrator Cheryl Sansano. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/16/2020 for a capacity of 6 non-ambulatory residents of which 1 may be bedridden.

LPA Velazquez along with Administrator Sansano observed the following:

Structure:

Facility is a two story house with 4 resident bedrooms, 2 bathrooms, living/dining area combination, storage room and kitchen downstairs. Upstairs there are 2 staff bedrooms with 1 staff bathroom. The facility has a white vinyl siding exterior with white trim. There is an attached 2 car garage. There is a front yard comprised of grass and plantars. The backyard has a shaded concrete area with seating for residents as well as a large grassy area with trees. The exit gate on the exterior of the home had a self-closing and self-latching mechanism but it did not operate properly.
Signal System:
The facility's central heating and air conditioning is controlled by a thermostat located in a hallway. All exit doors were equipped with an auditory alarm and were noted to be in operating condition. The facility utilizes a call button signal system that allows residents to summon staff when assistance is required. The call button system was tested and noted to be in operating condition.
Bedrooms Residents:
All bedrooms accommodate non-ambulatory residents with bedroom 3 designated for a bedridden resident. Emergency lighting was present in the facility. The resident bedrooms accommodate residents' furnishings.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020

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: WE CARE SENIOR LIVING	FACILITY NUMBER: 306005806
	VISIT DATE: 08/14/2020

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Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower. Grab bars were present as a well as a non-skid mat.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were located in 2 linen cabinets in the hallway.
Emergency Phone Numbers, Exit Plan:
Readily available for review in the entry area of the facility.
Postings:
The Ombudsman and Complaint posters were posted in the entry area of the facility. Coronavirus (COVID-19) postings were observed in the main entry way, bathrooms, and kitchen.
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. Additional food and emergency supplies were stored on a shelf located in the storage room.
Smoke and Carbon Monoxide Detectors:
Smoke detector alert systems were interconnected tested and found operational. The 2 carbon monoxide detectors were tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the kitchen.
Fire Clearance:
Approved on 07/22/2020.
Toxins and Sharps:
Locked and stored in a unlocked cabinet located in the storage room. The knives and other sharp items are stored in a locked kitchen cabinet under the sink.
Water Temperature:
Tested and recorded at 106.8 degrees Fahrenheit in bathroom 1 and at 114.1 degrees Fahrenheit in bathroom 2.
Medications, First Aid Kit & Manual:
First Aid kit with manual is stored in a locked cabinet located in the kitchen. Medication was stored in a locked cabinet located in storage room.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020

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: WE CARE SENIOR LIVING	FACILITY NUMBER: 306005806
	VISIT DATE: 08/14/2020

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Resident and Staff Files:
Resident and staff records were stored in a locked cabinet located in the storage room.
Reading Material, Games, Equipment, & Materials:
The facility had materials, games, and equipment present in the facility that commensurate with their plan of operation.
Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance.

The following items need to be addressed prior to licensure:

Repair or replace the inoperable dishwasher
Remove all the items in the side yard such as table, weed killer, plastic bin storing cans of paint, broom, lawn mower, desk, mattresses, lamp, and cart
Repair the latch on the exit gate that is not self-latching
Obtain mattress pads for resident beds
Replace torn mattress cover on one resident bed
Obtain a shower curtain for one resident bathroom
Obtain 2 chairs for dining table to accommodate all residents
Obtain 2 chairs for the exterior seating area to accommodate all residents
Obtain 1 chair in the living area to accommodate all residents
Securely lock all cleaning supplies

Facility does not appear ready for licensure. Any items noted during today’s visit are to be corrected by August 28, 2020. LPA Velazquez will conduct a subsequent phone virtual Pre-Licensing visit to review the items listed above. An exit phone interview was conducted with Administrator Cheryl Sansano and a copy of this report was signed by LPA Patricia Velazquez. This report will be sent via email to Administrator Cheryl Sansano who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Administrator Cheryl Sansano agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange. LPA Velazquez provided the RO address to Administrator Cheryl Sansano.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020

LIC809 (FAS) - (06/04)

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