306005977-2-9-2024-22-AS-RQUZ-D2ARZ5-20240209122722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005977
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:27:33 PM

Document Has Been Signed on 02/09/2024 12:27 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:	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:	02/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Vivian Ann Ortiz- Luis, Administrator		TIME COMPLETED:	01:26 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	On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called Administrator (AD) Vivian Ann Ortiz-Luis and explained the nature of the visit. (AD) Ortiz-Luis arrived during today's visit. This facility is licensed to provide services to age range 60 and over, approved for six (6) Non-Ambulatory Residents of which 1 (one) may be bedridden in Room #3 only, and has a hospice waiver for six (6) residents. There are four (4) residents in care of which (3) three residents are receiving hospice care services There are no active COVID-19 cases in the facility at this time. Administrator Ortiz-Luis has an Administrator Certificate with expiration date of 9/8/2025. LPA Rosie Quiroz along with (CG1) toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed two of four residents in their bedroom resting and 2 of four residents in the dining area with staff supervision. LPA Quiroz interacted and interviewed with staff and residents during today's visit. Between 10:06am-10:20am while conducting inspection tour of the kitchen area, LPA Quiroz observed expired condiments, food items and expired canned food with expiration dates varying from 6/1/2020- 10/19/2023. This was verified with (CG1) and (AD) Ortiz-Luis. (See LIC 809-D) LPA Quiroz inspected resident's bedrooms and bathrooms. Water temperatures were recorded to be between 107.7-109.4 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area backyard for residents and visitor's enjoyment in backyard area. CONTINUED ON NEXT LIC 809-C PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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: 02/09/2024

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CONTINUED...During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control.

Citation was issued during today’s visit.

An exit interview was conducted with (AD) Ortiz-Luis and a copy of this report, LIC 811-Confidential names, LIC 809-D page and Appeal Rights were provided to (AD) Ortiz- Luis at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/09/2024 12:27 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirement(b)(8): All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obsevation conducted during facility kitchen inspection area and interview conducted with (CG1), the licensee did not comply with the section cited above. While inspecting kitchen area, LPA Quiroz observed expired condiments, food items and canned goods with expiration dates varying from 6/1/2020-10/19/2023. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/12/2024
	Plan of Correction
1 2 3 4	During today's visit, (AD) Ortiz-Luis discarded expired food items and will provide inservice training to staff identified on LIC 500 on CCCR 87555 GENERAL FOOD SERVICE REQUIREMENTS by POC due date of 2/12/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC809 (FAS) - (06/04)

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