306005829-9-8-2022-22-AS-RQUZ-CJ3PBV-20220908111057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005829
Report Date: 09/08/2022
Date Signed: 09/08/2022 11:11:30 AM

Document Has Been Signed on 09/08/2022 11:11 AM - 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:	MT. SHERROD HOME, LLC.		FACILITY NUMBER:	306005829
ADMINISTRATOR:	VIVIAN LUIS-ORTIZ		FACILITY TYPE:	740
ADDRESS:	16550 MT. SHERROD CIRCLE		TELEPHONE:	(714) 839-4417
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 5	DATE:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Vivian Luis-Ortiz, Administrator, Thi Doan, Co-Licensee		TIME COMPLETED:	11:10 AM

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

On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection-Infection Control visit. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by caregiver and explained the nature of the visit. Administrator (AD)Vivian Ortiz-Luis and Thi Doan, Co-Licensee arrived during today's visit.

This facility is licensed to provide services to residents age range 60 and over, 6 Non-Ambulatory Residents of which 1 (one) may be bedridden and has a hospice waiver for six (6) residents. Facility is currently providing hospice services to two (2) residents. (AD)Vivian Ortiz-Luis has an Administrator Certificate with expiration date of 09/08/2023.

On or about 10:32am LPA Quiroz along with (AD) Ortiz-Luis toured the inside and outside of facility. The staff working at facility on today's date were observed to be wearing face masks upon arrival to facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed one (1) resident in dining-room/living room area visiting with Family, two (2)residents resting in living room area with staff supervision and two residents were observed in their bedrooms on their cell phone. Five of five residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating shaded area with table and chairs for resident’s enjoyment. Facility has completed the LIC 808 Mitigation plan and infection control.

CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: MT. SHERROD HOME, LLC.	FACILITY NUMBER: 306005829
	VISIT DATE: 09/08/2022

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
26
27
28
29
30
31
32

During today's inspection visit, LPA Quiroz reviewed five of five resident records. AD Ortiz-Luis indicated "all residents and staff at facility are fully vaccinated for COVID-19 and have received 2 boosters ."

During today's visit, water temperature was recorded to be 105 degrees Fahrenheil and indoor facility temperature was recorded to be between 85-88 degrees Fahrenheit. Co-Licensee Thi Doan indicated "I just purchased 4 portable air conditioners. I installed two last week and installing two more today." LPA Quiroz observed two portable air conditioners installed inside facility and two portable air conditioners waiting to be installed in garage area."

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

This report was reviewed with AD Ortiz-Luis and Co-Licensee Thi Doan and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2