306005868-10-10-2022-22-AS-CDPO-CK3TW3-20221010150453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005868
Report Date: 10/10/2022
Date Signed: 10/10/2022 03:05:03 PM

Document Has Been Signed on 10/10/2022 03:05 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:	ELEONOR'S PLACE 1		FACILITY NUMBER:	306005868
ADMINISTRATOR:	AVENDANO, DARYLL		FACILITY TYPE:	740
ADDRESS:	24152 JAGGER STREET		TELEPHONE:	(949) 547-5377
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	10/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Facility Administrator - Mark Cruz		TIME COMPLETED:	03:15 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 (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Mark Cruz about visit. Staff on duty (S1) provided tour of the facility with LPA De Perio. As of 10/10/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility The PUB475 "See Something, Say Something" poster was also observed to be located in the kitchen. LPA observed the Administrator's Certificate for Mark Cruz which expires on 12/2/22 and Eleonor Avendano which expires on 10/28/23. LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a two level structure and is licensed for residents 60 years and older, 6 non-ambulatory, 0 bedridden and 6 hospice. For this visit, there are a total of 6 residents in care, of which 1 is on hospice, and 0 bedridden. On the first floor, there are a total of 6 private bedrooms for residents, and 3 bathrooms. On the second level, there is one bathroom and 2 bedrooms, which is utilized for staff. LPA De Perio observed and verified that there are no residents residing on the second floor. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 108.8 degrees Fahrenheit and hand washing signs were also posted in each restroom. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

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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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: ELEONOR'S PLACE 1	FACILITY NUMBER: 306005868
	VISIT DATE: 10/10/2022

NARRATIVE

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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were located in a kitchen pantry and is locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen.

LPA De Perio observed facility's Emergency Disaster and Evacuation Plan. Facility had back-up emergency food and water supply, located in the garage and in the medication cabinet. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in a cabinet located in the facility hallway. Toxins were also observed to be locked and inaccessible to residents.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which was self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Cruz. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Cruz to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELEONOR'S PLACE 1	FACILITY NUMBER: 306005868
	VISIT DATE: 10/10/2022

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LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Cruz.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Cruz to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Cruz and a copy of this report and copies of the regulations discussed were provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC809 (FAS) - (06/04)

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