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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005838
Report Date: 08/19/2021
Date Signed: 09/01/2021 07:26:16 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:GENTLE CARING HOMEFACILITY NUMBER:
306005838
ADMINISTRATOR:LOURDES LAT, MARIAFACILITY TYPE:
740
ADDRESS:26762 CARLOTA DR.TELEPHONE:
(949) 874-4426
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Paola Olivares and Maria Lourdes LatTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Paola Olivares and Julia Jimenez. The focus of the visit was Infection Control. Administrator Maria Lourdes Lat was contacted and arrived a short time after LPA.During the visit LPA toured the facility with Paola Olivares and the following was observed:

Covid signage was posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was made available. Facility has required Department postings. Administrator Certificate for Maria Lat expires on 7/5/21. Ms. Lat stated she is awaiting her new certificate. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed having lunch. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as PIN 21-32-ASC Updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Maria Lat.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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