306005822-8-8-2024-22-AS-RMAZ-D7XU2X-20240808151241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005822
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:12:47 PM

Document Has Been Signed on 08/08/2024 03:12 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:	AMPARO ELDER CARE HOME		FACILITY NUMBER:	306005822
ADMINISTRATOR:	WHITTAKER, NORIE		FACILITY TYPE:	740
ADDRESS:	2229 E HOOVER AVE		TELEPHONE:	(949) 800-9337
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 5	DATE:	08/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Salvador Urayenza		TIME COMPLETED:	03:30 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 (LPAs) Ruth Martinez and William Vanegas is conducting this unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and was greeted and granted entry by staff and LPA Martinez explained the nature of the visit. There are five residents at the facility and there are three residents receiving hospice services currently. Norie Whittaker, Administrator arrived at a later time and met with LPAs. LPAs began the tour of the inside and outside of the facility. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage closet located in living room. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 105.7 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and, in a cabinet, located in laundry unit. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed there are shaded seating areas for residents’ enjoyment. LPAs observed a fire extinguisher with service date of August 11, 2023, in living room. Fire drills are conducted every three months. LPAs began review of records. LPAs reviewed three Continued LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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: AMPARO ELDER CARE HOME	FACILITY NUMBER: 306005822
	VISIT DATE: 08/08/2024

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resident records. All the required documentation was present and current in the residents’ files reviewed. LPAs reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPAs observed records reviewed have a current First Aid certificate. LPAs spoke with alert residents during the inspection regarding the quality of their care

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

This report was reviewed with the facility representative, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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