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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006004
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:04:25 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:HEYDAY SENIOR LIVING OF FOUNTAIN VALLEYFACILITY NUMBER:
306006004
ADMINISTRATOR:ALIM, REA BADILLOFACILITY TYPE:
740
ADDRESS:18480 SANTA ALBERTA CIRTELEPHONE:
(562) 303-0130
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
10/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Rea Badillo AlimTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Administrator Rea Badillo Alim toured facility.

Fire clearance approval was received on 08/11/21. Structure: Facility is a one story, 5 bedroom (4 Residents bedrooms and 1 caregiver bedroom) 2 bathroom house with an attached garage and a beige exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Residents bedrooms meet Licensing requirements. Bathrooms: facility bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface mats in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on all sliding/exit doors. Appliances: Stove and refrigerator are operational. Toxins: LPA observed toxins secured in storage pantry inside locked garage door. Water Temperature: Tested and recorded at 106.3 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility does toss ball exercises, movie nights, puzzles, coloring books, math exercises and walking. Medications, First-Aid Kit & Book: Facility has first aid kit with manual present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on one side of facility as required. LPA observed shaded outdoor seating.

CONTINUED ON LIC 809C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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: HEYDAY SENIOR LIVING OF FOUNTAIN VALLEY
FACILITY NUMBER: 306006004
VISIT DATE: 10/14/2021
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Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating another licensed facility.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Administrator Rea Badillo Alim and a copy of report was left at facility
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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