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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005851
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:18:09 PM


Document Has Been Signed on 03/10/2022 12:18 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:RAV PREMERA CAREFACILITY NUMBER:
306005851
ADMINISTRATOR:PAO, WESLEYFACILITY TYPE:
740
ADDRESS:864 N. FORD AVETELEPHONE:
(714) 213-8596
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Remigo Villanueva, Caregiver
Jake Villanueva, Caregiver
Imelda Ramos, Caregiver		TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facilty in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregiving staff Remigo Villanueva, Jake Villanueva and Imelda Ramos after explaining the purpose of the visit and being temperature checked. Staff called Administrator Wesley Pao to notify him of the visit. Administrator was unable to assist with visit due to a medical appointment.

At approximately 11:45am, LPA accompanied by caregiver Remigo Villanueva began the tour of the facility. There are currently five (5) clients in care. Clients are observed relaxing in their bedrooms or in the common areas and appears well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. The six bedrooms are observed to have all required components and bathrooms observed are equipped with grab bars and slip mats. All smoke detectors are observed to be functional at this time.
LPA observed a check-in station next to the entrance of the facility where temperature checks are being documented for visitors. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs posted throughout. The facility has completed and submitted their LIC808 Mitigation Plan.
LPA observed a sufficient supply of food and water. A 30-day supply of medication is stored and locked in a kitchen cabinet. Facility has an adequate supply of PPE. LPA toured the outside of the facility. Outdoor furniture is present for the clients' enjoyment. Outside space is free of clutter and debris. There are no bodies of water on the premises. A Technical Advisory is being added to this report in regards to the presence of toxic substances outside of locked cabinets.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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