306005977-10-21-2021-22-AS-RQUZ-C7ZQAM-20211021120009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005977
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:00:22 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:	FOUNTAIN VIEW CARE HOME		FACILITY NUMBER:	306005977
ADMINISTRATOR:	ORTIZ-LUIS, VIVIAN ANN		FACILITY TYPE:	740
ADDRESS:	17688 SAN FRANCISCO ST		TELEPHONE:	(626) 272-5906
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 4	DATE:	10/21/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Vivian Ann Ortiz-Luis, Administrator		TIME COMPLETED:	12:05 PM

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA Quiroz was greeted and granted entry and met with Administrator Vivian Ann Ortiz-Luis.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 2/18/2021 for a capacity of six (6) residents, five (6) Non-Ambulatory residents; of which one (1) may be bedridden and hospice waiver for (6) six residents.

Administrator Vivian Ann-Ortiz Luis has an Administrator Certificate with expiration date of 9/8/2021. Administrator Ortiz-Luis indicated "Completed and submitted Certificate renewal on 7/2/2021, and waiting for new Administrator Certificate. Administrator Ortiz-Luis agreed to submit copy of new Administrator Certificate to CCL upon receiving new Administrator Certificate.

LPA Quiroz provided consultation on Title 22 California Code of Regulations (CCR) and on new Inspection Tool.

At approximately 10::37am, LPA Quiroz along with Administrator Ortiz-Luis commenced the inspection tour.

During today's inspection visit, LPA Quiroz observed the following:

Structure:

Facility is a one story building. The first floor consists of: 6 private resident bedrooms, (1) one caregiver bedroom, (2) two full bathrooms, one (1) half bathroom. Bedroom #6 is designated as bedridden resident bedroom only. The resident bedrooms will accommodate residents' furnishings. There is one living room, kitchen with dining area, 2 car garage with operational washer and dryer, and back yard with outdoor furniture.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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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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: FOUNTAIN VIEW CARE HOME	FACILITY NUMBER: 306005977
	VISIT DATE: 10/21/2021

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Toxins: Will be locked and stored in secured closet in garage area, not accessible to residents in care.

Water Temperature: Water temperatures were tested and recorded in 2 of 2 resident bathrooms to be 108.4 and 111.2 degrees F.

Linens and Hygiene Supplies: Facility will have available linens upon residents move in, and extra linen and hygiene supplies available for residents in care, and stored in linen closet in main hallway.

Medications, First Aid Kit & Manual: Medication will be stored secured and locked in medication closet near main hallway. First Aid Kit and Manual will be stored in medication closet readily available for staff and residents in care.

Resident and Staff Files: Records will be kept in a locked and secured area in garage area.

Signal System: Facility has no internal heating or air conditioner. LPA Quiroz observed 5 wall mounted air conditioner systems, and 2 portable air conditioners. The temperature inside the facility was recorded to be 69 degrees F.

Bedrooms Residents: Bedrooms will accommodate residents.

Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in shower.

Emergency Phone Numbers, Exit Plan, and Sample Menu: Readily available and posted in dining area.

Food Service: Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen, pantry and in garage area. LPA Quiroz observed second refrigerator for extra food storage in garage area.

Fire Extinguisher: LPA Quiroz observed 2 fire extinguishers in facility, Last serviced on 9/2020. Administrator Ortiz-Luis indicated "They are scheduled to come out any day to service them."

Fire Clearance: Approved on 5/26/2021. LIC 610 E form observed posted in dinging area readily available for staff and residents in an event of an emergency.

Appliances: Appliances were observed operational and in good repair.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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: FOUNTAIN VIEW CARE HOME	FACILITY NUMBER: 306005977
	VISIT DATE: 10/21/2021

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Component III: Component III was completed today with Administrator Vivian Ann Ortiz-Luis.

On 5/26/2021, the fire clearance was granted for a capacity of 6 non-ambulatory residents of which 1 may be bedridden. Bedridden resident in Bedroom #6 only.

Administrator Vivian Ann Ortiz-Luis was reminded of the statute that requires facility to notify Rosie Quiroz, Licensing Program Analyst at (559) 753-4610 within 5 business days of admitting the first resident new resident. This notification may be done by phone, mail, email or fax. LPA Rosie Quiroz provided Applicant with business card to facilitate communication with LPA Quiroz.

Facility is ready to be licensed.

An exit interview was conducted with Administrator Vivian Ann Ortiz-Luis, 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: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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