306006006-8-25-2021-22-AS-SFRK-C68UPJ-20210825154538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006006
Report Date: 08/19/2021
Date Signed: 08/25/2021 03:45:46 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 COSTA MESA		FACILITY NUMBER:	306006006
ADMINISTRATOR:	ALIM, REA BADILLO		FACILITY TYPE:	740
ADDRESS:	2750 LORENZO AVE		TELEPHONE:	(949) 558-4478
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 3	DATE:	08/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Licensure Alim Rea Badillo		TIME COMPLETED:	12:15 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	Licensing Program Analyst (LPA) Shobhana Frank arrived to conducted an announced visit to the facility for purpose of a Pre-licensing/Comp III Visit. LPA was greeted at the door by Licensure Alim Rea Badillo granted entry and lead the tour of the facility indoors and outdoors. The following was observed: An initial application to operate Residential Care Facility for the Elderly, age 60 years and over, for (6) capacity, (6) non-ambulatory resident was submitted to CCL on 04/28/2021. LPA observed 3 non - ambulatory residents at the time of Pre licensing inspection, from three residents 1 residents is receiving hospice care. The facility has 3 staff and 3 residents and all are vaccines Pfizer vaccine on February 18, 2021 from CVS pharmacy. structure: Facility is a single story 4 bedrooms and 2 bathrooms house with an attached garage. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, visitors log. LPA observed COVID posters throughout the facility. LPA observe the facility to be clean and in good repair. Bedrooms Residents: two bedrooms are single occupancy and two bedrooms are shared bedrooms. All bathrooms have a working toilet, wash basin, grab bar, rolling shower, accommodates non-ambulatory clients in a wheel chair. Bathroom: One Activity room Adequate supply of linens and hygiene supplies are stored in main hallway closet. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review in the kitchen Food Service: Adequate supply of 7- day non-perishable and 2- day perishables are stored in the kitchen. Kitchen was observed to be clean and in order. Sharps were observed to be kept in a locked closet.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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 2

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 COSTA MESA	FACILITY NUMBER: 306006006
	VISIT DATE: 08/19/2021

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
26
27
28
29
30
31
32

Smoke Detectors:
Smoke detectors which were operational, carbon monoxide detectors which were operational auditory device in each bedrooms and bathrooms are operable, facility has water fire sprinklers throughout the facility.
Smoke detectors and carbon monoxide were tested. Fire clearance was granted on 7/23/2021

Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational.
The refrigerators and freezers were installed with the required thermostats.
Toxins: Locked/stored in cabinet by the laundry room.
Water Temperature:
Tested and recorded at Bathroom : 109.2 degrees Fahrenheit.
Medications, First-Aid Kit
In kitchen stored in a locked by the kitchen cabinet.
Back yard: Back yard with covered patio and without hazards, outdoor and indoor passageways are free of obstruction.
Clients & Staff Files:
Location: locked & located in cabinet in the kitchen cabinet. .
Reading Material, Games, Equipment & Materials:
The facility has purchased and will transfer board games, books, exercise periods, puzzles, art (coloring, sketching, etc.) and other recreational materials for the client's use locate by living room. There are no bodies of water located on premises.
Facility has provided copy of Certificate of Liability Insurance - expires in 4/1/2022.
Facility appears to be ready for licensure. LPA will complete the administrative process, and contact Licensee when the licensing procedure is completed.
An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2