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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000950
Report Date: 06/08/2022
Date Signed: 06/08/2022 02:13:37 PM


Document Has Been Signed on 06/08/2022 02:13 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:BREA RETREATFACILITY NUMBER:
306000950
ADMINISTRATOR:VIOREL SIGHEARTAUFACILITY TYPE:
740
ADDRESS:1318 W.ALTA MESA DR.TELEPHONE:
(562) 694-2206
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 6DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Viorela PopTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Lydia Martinez and Licensing Program Manager Armando Lucero made an unannounced visit to the facility for the purpose of conducting a Required - 1 - Year visit as LPA was not able to complete the Required 1 Year inspection that was initiated on 05/02/2022. This visit is focused primarily on Infection Control. LPM Lucero and LPA Martinez were allowed entry into the facility and met with Staff Delores "Ruth" Thomas and Lindsay Peta-Gay. Viorela Pop arrived shortly after and confirmed there are currently no cases or exposures of COVID-19 within the facility.

LPA and LPM observed the required Department posting on COVID-19 precautions at entrance of facility. There is a sign-in procedure in place and hand sanitizer for use. LPA observed that staff were wearing face masks. There were 6 Residents present during this visit. LPA and LPM along with Staff Ruth and Lindsey conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. A tour of Resident rooms was done and all rooms were within regulations. Residents were observed havibg lunch, during the visit. Bathrooms observed contained hand washing soap, toilet paper and paper towels and had the proper hand washing signs posted. Facility has operating smoke and carbon monoxide detectors. Facility noted Fire Extinguisher was charged. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the Residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan, and a secured location for Resident's medication and files. Facility has 30 days supply of medications for the Residents. LPA reviewed a Resident file and emergency contact information and Physicians reports was up to date.

LPA consulted with staff on the importance of masks, screening visitor and documenting temperature. LPA reminded staff to review Department PINS and to keep updated on Department Requirements regarding Infection Control, Testing and Masking Guidelines. No deficiencies were noted during today's visit. An exit interview was conducted and a copy of this report will be provided via email.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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