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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423843
Report Date: 03/08/2022
Date Signed: 03/08/2022 04:27:54 PM

Document Has Been Signed on 03/08/2022 04:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:FORTUNE CARE CENTERFACILITY NUMBER:
366423843
ADMINISTRATOR:LAYGO, ARCELIAFACILITY TYPE:
735
ADDRESS:22328 BROKEN LANCE RDTELEPHONE:
(760) 247-7925
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Arcelia Laygo TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility for an annual inspection. LPA met with Administrator Arcelia Laygo

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients. Covid -19 Testing was being preformed at the time of visit.

LPA toured the facility inside and out and there were no health and safety concerns. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The outdoor and indoor hallways were also free of obstruction.

Cleaning supplies are locked in the in laundry room cabinet. Residents medications were kept in a safe and locked cabinet in the kitchen.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

The client rooms had the required furniture and sufficient lighting. The bathrooms accommodate the needs for bathing and showers have non-slip flooring.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: FORTUNE CARE CENTER
FACILITY NUMBER: 366423843
VISIT DATE: 03/08/2022
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The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature in the main bathrooms. The hot water temperature measured at 105.2 degrees F.

LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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