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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006004
Report Date: 10/13/2022
Date Signed: 10/13/2022 01:45:09 PM


Document Has Been Signed on 10/13/2022 01:45 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 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: 2DATE:
10/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rea Badillo Alim, AdministratorTIME COMPLETED:
01:52 PM
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On today's date, while conducting a 10 day Complaint Inspection visit for complaint control #22-AS-20221011161849, LPA Quiroz requested and reviewed records for Resident 1 (R1). R1's records indicate resident was admitted into hospice on 2/25/2022 , and was changed from Non-Ambulatory status to bedridden status effective 9/9/2022.

Administrator (AD) Rea Badillo Alim will schedule a physician report medical assessment for R1 by 10/14/2022 and submit updated medical assessment physician report (LIC 602) to CCL by 10/31/2022.

During today's visit, LPA Quiroz provided consultation to (AD) Rea Badillo Alim regarding California Code Of Regulation 87202(a)(1)(2): Fire Clearance.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with (AD) Rea Badillo Alima, and a copy of this report, LIC 811- Confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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