306006004-9-8-2022-22-AS-RQUZ-CJ3RGP-20220908130105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006004
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:01:33 PM

Document Has Been Signed on 09/08/2022 01:01 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:	HEYDAY SENIOR LIVING OF FOUNTAIN VALLEY		FACILITY NUMBER:	306006004
ADMINISTRATOR:	ALIM, REA BADILLO		FACILITY TYPE:	740
ADDRESS:	18480 SANTA ALBERTA CIR		TELEPHONE:	(562) 303-0130
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 2	DATE:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Norhayda De Leon, Caregiver and Mavivien Migliorini, Administrator		TIME COMPLETED:	01:10 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection -Infection Control visit. LPA Quiroz was greeted and granted entry into the facility by caregiver and explained the nature of the visit. Administrator Mavivien Migliorini arrived shortly after.

This facility is licensed to provide services to residents age range 60 and over, approved for (6) six Non Ambulatory residents, of which (1) one may be bedridden. Approved hospice waiver for two (2) residents. Bedroom #3 is cleared for bedridden resident. Facility is currently providing hospice services to two (2) residents. (AD) Mavivien Migliorino has an Administrator Certificate with expiration date of 6/11/2024.

On or about 12:17pm, LPA Quiroz along with (AD) Migliorini toured the inside and outside of facility. The staff working at facility on today's date were observed to be wearing face masks upon arrival to the facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed two of two residents in their bedrooms eating their lunch. Two of two residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility; however LPA Quiroz and visitor who arrived to visit Resident 1 walked into facility without being COVID-19 screened and not wearing a face mask. (SEE LIC 9102 TV)

Facility indicated they are taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating shaded area with table and chairs for resident’s enjoyment. Facility has completed the LIC 808 Mitigation plan and infection control.

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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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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: HEYDAY SENIOR LIVING OF FOUNTAIN VALLEY	FACILITY NUMBER: 306006004
	VISIT DATE: 09/08/2022

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During today's inspection visit, LPA Quiroz reviewed two of two resident records. (AD) Migliorini indicated "all residents and staff at facility are fully vaccinated for COVID-19."

During today's visit, water temperature was recorded to be within normal limits, and indoor facility temperature was recorded to be 84 degrees Fahrenheit. LPA Quiroz observed one portable air conditioner, one industrial fan and fans running throughout facility during today's visit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. An Advisory Note-Technical Violation LIC 9102 TV was assessed on today's date.

This report was reviewed with (AD) Migliorino, and a copy of this report, LIC 9102TV and LIC 811-Confidential names were 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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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