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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005928
Report Date: 06/07/2021
Date Signed: 06/07/2021 04:09:10 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:MOM'S RETREAT BOARD AND CARE HOMEFACILITY NUMBER:
306005928
ADMINISTRATOR:GARCIA, GABRIELAFACILITY TYPE:
740
ADDRESS:607 S. PINE DRIVETELEPHONE:
(714) 829-6024
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 0DATE:
06/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gabriela GarciaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez contacted the facility via FaceTime to conduct a Pre-Licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified herself to Applicant Gabriela Garcia and discussed the purpose of the announced virtual call. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to CCL on 11/13/2020.

Facility is a one story house, with 4 bedrooms and 2 bathrooms. LPA Martinez toured the interior and exterior premises. Fire Extinguisher was observed, mounted and charged. Smoke detectors, carbon monoxide detectors and auditory devices have been tested and are operational. Medications will be stored in a locked cabinet in the laundry room; along with sharps and toxins/cleaning supplies. Beds were made with appropriate linens. Furniture appears safe and adequate. Hot water temperature is tested by Administrator and is within regulatory requirements. The applicant has submitted a request for a Hospice Waiver. A plan to care for residents with Dementia was submitted. LPA observed all physical plant safeguards for Dementia to be within regulatory requirements. The Applicant states that she does not plan to advertise for Dementia. A Fire Clearance for a capacity of six, (non ambulatory) residents was granted on 01/13/2021. The Component III was completed with Applicant. Applicant demonstrated and exhibited a clear concise comprehensive knowledge of medication protocols, documentation; and wound preventative care.

The Pre-Licensing evaluation has been completed. It appears this facility meets the requirements for licensure and a Hospice Waiver. The license and waiver will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted with Applicant Garcia. This report will be emailed and an electronic email read receipt confirms receiving of the report. Applicant agrees to sign the report and email back a copy to LPA.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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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