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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006004
Report Date: 07/01/2024
Date Signed: 07/01/2024 05:14:56 PM


Document Has Been Signed on 07/01/2024 05:14 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
ORANGE COUNTY RO, 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:
07/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Fregil JimenezTIME COMPLETED:
05:30 PM
NARRATIVE
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On July 1, 2024, Licensing Program Analyst (LPA) Edward Kim and Licensing Program Manager Lourdes Montoya conducted a case management deficiency visit. LPA and LPM observed the following deficiencies during a pre-licensing visit.

1) LPA observed furnace had an open flame and wasn't secured safely in the garage, which needs follow up with Socal gas
2) LPA observed the electric stove front left burner was not operable.
3) LPA observed certificate of liability shows three facilities listed on one policy. with a total of $1,000,000 per claim and aggregate $3,000,000 for all three facilities.
4) LPA observed and interviewed staff that there was no LIC 308 completed and sent to CCLD for a temporary designated administrator.

Deficiencies were cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report and appeal rights provided to staff Fregil Jimenez.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 07/01/2024 05:14 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: HEYDAY SENIOR LIVING OF FOUNTAIN VALLEY
FACILITY NUMBER: 306006004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2024
Section Cited
CCR
87405(a)

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87405(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
This requirement was not met as evidenced by:
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Staff Fregil Jimenez agrees to submit a LIC 308 to CCLD via email to edward.kim@dss.ca.gov by July 8, 2024.
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LPA observed and per interview with staff, licensee/administrator is out of the country from June 15, 2024 to July 6, 2024. This is a potential health, safety, and personal rights risk to all persons in care
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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: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3