306006161-5-24-2022-22-AS-RQUZ-CEQSXS-20220524141626

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006161
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:16:32 PM

Document Has Been Signed on 05/24/2022 02:16 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:	FOUNTAIN VALLEY CARE HOME, INC		FACILITY NUMBER:	306006161
ADMINISTRATOR:	ARGOSINO, DULCE		FACILITY TYPE:	740
ADDRESS:	15938 MAIDSTONE ST		TELEPHONE:	(714) 418-0341
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 5	DATE:	05/24/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Dulce Argosino, Licensee/Administrator		TIME COMPLETED:	02:32 PM

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an Announced scheduled visit to the facility for purpose of a Pre-Licensing evaluation due to Change of Ownership. LPA Quiroz was greeted, COVID-19 screened, granted entry and met with Licensee/ Administrator (L/AD) Dulce Argosino.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 3/21/2022 for a capacity of six (6) Non-Ambulatory residents. Administrator Dulce Argosino has an Administrator Certificate with expiration date of 3/23/2023.

LPA Quiroz provided consultation on Title 22 California Code of Regulations (CCR) and on new Inspection Tool.

At approximately 1:40pm, LPA Quiroz along with (L/AD) Dulce Argosino commenced the inspection tour.

During today's inspection visit, LPA Quiroz observed the following:

Structure: Facility is a one story building, which consists of: four (4) private resident bedrooms, one (1) shared resident bedroom, (1) one caregiver bedroom, living-room, kitchen with dining area, office staff area, garage area with operational washer and dryer and backyard area with outdoor furniture for residents and visitors enjoyment. The residents bedrooms will accommodate residents' furnishings.

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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: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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: FOUNTAIN VALLEY CARE HOME, INC	FACILITY NUMBER: 306006161
	VISIT DATE: 05/24/2022

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CONTINUE...Toxins: Will be locked and stored in secured closet in garage area, not accessible to residents in care.

Water Temperature: Water temperatures were tested and recorded in 2 of 2 resident bathrooms to range between 110.0 degrees F and 112.0 degrees F.

Linens and Hgiene Supplies: Facility will have available linens upon residents move in, and extra linen and hygiene supplies available for residents in care, and stored in linen closet in main hallway.

Medications, First Aid Kit & Manual: Medication will be stored secured and locked in medication closet in locked and secured office area. First Aid Kit and Manual will be stored in medication closet readily available for staff and residents in care.

Resident and Staff Files: Records will be kept in a locked and secured area in office area.

Signal System: Facility has internal heating and air conditioner. The temperature inside the facility was recorded to be 75 degrees F.

Bedrooms Residents: Bedrooms will accommodate residents.

Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in shower.

Emergency Phone Numbers, Exit Plan, and Sample Menu: Readily available and posted in dining area.

Food Service: Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen, pantry and in garage area. LPA Quiroz observed second refrigerator for extra food storage in garage area.

Fire Extinguisher: LPA Quiroz observed 2 fire extinguishers in facility, Last serviced on 2/14/2022.

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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: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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: FOUNTAIN VALLEY CARE HOME, INC	FACILITY NUMBER: 306006161
	VISIT DATE: 05/24/2022

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CONTINUED...

Fire Clearance: Approved on 5/04/2022 for a capacity of 6 Non Ambulatory residents. LIC 610 E form observed posted by facility entrance readily available for staff and residents in an event of an emergency. LIC 808 Mitigation Plan dated 3/3/2022 was reviewed and approved on today's date. A copy of LIC 808 was observed and kept in facility's emergency binder.

Appliances: Appliances were observed operational and in good repair.

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Component III: Component III was completed today with Administrator Dulce Argosino.

Licensee/ Administrator Dulce Argosino was reminded of the statute that requires facility to notify Rosie Quiroz, Licensing Program Analyst at (559) 753-4610 within 5 business days of admitting the first new resident. This notification may be done by phone, mail, email or fax. LPA Rosie Quiroz provided Applicant with business card to facilitate communication with LPA Quiroz.

Therefore, the facility physical plant meets requirements of Title 22 Regulations.

The pre-licensing inspection has been completed. License will be granted upon completion of a final review of the application and approval by the CAU.

An exit interview was conducted with Administrator Dulce Argosino, and a copy of this report was provided via email.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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