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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005822
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:02:31 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:AMPARO ELDER CARE HOMEFACILITY NUMBER:
306005822
ADMINISTRATOR:WHITTAKER, NORIEFACILITY TYPE:
740
ADDRESS:2229 E HOOVER AVETELEPHONE:
(949) 800-9337
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 1DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Norie WhittakerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual visit. LPA arrived at the facility was greeted and granted entry into the facility by caregiver. LPA met with caregiver and explained the nature of the visit. Administrator arrived shortly after.

LPA Martinez toured the facility. There is one resident in care and no active covid-19 cases. LPA observes the one resident in their bedroom. Resident appeared clean and well taken care of. LPA observed a check in station in the main entry of the facility with logs per covid guidelines. LPA observed required department postings, covid-19 precautionary postings, and hand washing signs in the restrooms. All restrooms observed to have soap/sanitizer and appeared clean. Residents bedrooms appeared clean and sanitary with all required components. Facility is taking covid-19 precautionary measures daily. LPA observed the emergency disaster and evacuation plan posted. Facility has food and water supply as well as PPE supplies. Facility has completed the LIC808 Mitigation Plan and LPA Martinez approved the plan on site.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, this report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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