306006194-7-25-2022-22-AS-RQUZ-CGNUUC-20220725155315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006194
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:53:27 PM

Document Has Been Signed on 07/25/2022 03:53 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:	LOS TIEMPOS SENIOR LIVING #2		FACILITY NUMBER:	306006194
ADMINISTRATOR:	FIGUEROA, ROSA JANETH		FACILITY TYPE:	740
ADDRESS:	9932 DEBIOIS AVE		TELEPHONE:	(909) 238-7967
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 0	DATE:	07/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rosa Figueroa, Administrator		TIME COMPLETED:	03:53 PM

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At approximately 1:30pm, Licensing Program Analyst (LPA) Rosie Quiroz conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA Quiroz was greeted and granted entry and met with Licensee/Administrator (L/AD) Rosa Figueroa.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 06/02/2022 for a capacity of six (6) Non-Ambulatory residents and a hospice waiver for three (3) residents.

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

At approximately 1:58pm, LPA Quiroz along with (L/AD) Rosa Figueroa commenced the inspection tour.

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

Structure:

Facility is a one story building, which consists of: 4 resident bedrooms of which 3 bedrooms are private bedrooms and 1 shared bedroom. The resident bedrooms will accommodate residents' furnishings. There are 2 bathrooms, living room, kitchen with dining area, 2 car garage, office area in garage area, operational washer and dryer,and back yard with outdoor furniture.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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: LOS TIEMPOS SENIOR LIVING #2	FACILITY NUMBER: 306006194
	VISIT DATE: 07/25/2022

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

Water Temperature: Water temperatures was tested and recorded in 2 of 2 bathrooms to be 113.4 and 113.8 degrees F.

Linens and Hygiene 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 near main hallway. 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 in garage.

Signal System: Central air/heating system installed with a central panel to control temperature. The temperature inside the facility was recorded to be 70 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. Second refrigerator observed in garage area.

Fire Extinguisher: Two, fully charge Last serviced on 7/08/2022.

Fire Clearance: Approved on 7/08/2022. LIC 610 E form observed posted in dinging area readily available for staff and residents in an event of an emergency.

Appliances: Appliances were observed operational and in good repair.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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: LOS TIEMPOS SENIOR LIVING #2	FACILITY NUMBER: 306006194
	VISIT DATE: 07/25/2022

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Component III: Component III was completed today with Licensee/Administrator Rosa Figueroa.

On 07/08/2022, the fire clearance was granted for a capacity of 6 non-ambulatory residents.

Licensee/Administrator Rosa Figueroa was reminded of the statute that requires them to notify Rosie Quiroz, Licensing Program Analyst at (559) 753-4610 within 5 business days of admitting the first 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.

Facility is ready to be licensed.

An exit interview was conducted with Licensee/Administrator Rosa Figueroa and a copy of this report was provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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