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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423843
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:52:37 AM

Document Has Been Signed on 05/19/2023 11:52 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Joel Tayao, Staff MemberTIME COMPLETED:
12:00 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Fortune Care Adult Residential Facility unannounced to conduct the Annual Inspection. LPA knocked on the main entrance door and was greeted and granted entry by staff member, Joel Tayao. LPA was requested to sign in and have temperature taken, then provided a space to work. LPA was informed the current census is 4. At time of visit, residents were preparing to leave for their prospective Day Programs. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are all equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the temperature from the bathroom faucet, which read at 110 degrees F. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as; the personal rights and disaster plans were posted in a common areas throughout the facility and in each resident's room. Cleaning supplies for the kitchen are securely stored along with sharps and other toxins in a cabinet under the sink. There is a designated storage space for client/staff files. Medications were secure in a kitchen cabinet. Each resident has their own labeled bin where their own medications are kept along with their Medication Records. The facility had emergency and first aid kits readily available for clients in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed. A food menu is posted on the refrigerator for reference.
Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FORTUNE CARE CENTER
FACILITY NUMBER: 366423843
VISIT DATE: 05/19/2023
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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. A staff schedule was observed posted in the facility's kitchen. Although no staff live on grounds, the facility maintains a staff room for those who wish to rest before or after their shifts. LPA observed a number of activity materials made available to residents.

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. P & I funds were counted at random and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff members. The facility last conducted a disaster drill for fire on 5/1/23 and for earthquake 4/33/23. The facility staff conduct these drills on a monthly basis per documentation in facility file. Fire extinguisher last inspected June 2022

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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