306006161-6-12-2024-22-AS-MTEA-D66Q3N-20240612114902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006161
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:49:22 AM

Document Has Been Signed on 06/12/2024 11:49 AM - 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:	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:	06/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Dulce Argosino		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:50 AM, LPA Tea was greeted and granted entry into the facility by the administrator, Dulce Argosino and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for six. Currently there are five residents, of which three are on hospice during today's visit.

At 9:02 AM, LPA Tea reviewed five resident files and two staff files. Residents files and staff files contained all required documentation. Administrator certificate expires on March 23, 2025.

LPA Tea along with the Administrator toured the facility at 9:42 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 5 resident bedrooms, which one is shared, 1 staff room, 2 full bathrooms, living room, dining room, and kitchen. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.7 F degrees and 110.4 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen cabinet. LPA also observed toxin substances to be secured and locked and inaccessible to clients in the garage. Fire extinguishers are fully charged. The facility’s last fire drill was conducted on June 06, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and the exit gate is self latching and operational. The backyard has a small garden area.

Annual continuation on LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FOUNTAIN VALLEY CARE HOME, INC	FACILITY NUMBER: 306006161
	VISIT DATE: 06/12/2024

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LPA observed emergency food and water supply in the garage. Facility provides activities in the form of outdoor activities such as going on walks and exercises. The residents do puzzles such as sudoku, and reading newspapers, books, and magazines. Residents also enjoy watching sports events.

At 10:14 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

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

This report was reviewed with administrator, Dulce Argosino and a copy of this report LIC809, 809-C, LIC858, LIC859, was read and provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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