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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002414
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:50:02 PM

Document Has Been Signed on 03/08/2022 01:50 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:FREEDOM SPRINGS MANORFACILITY NUMBER:
306002414
ADMINISTRATOR:MAYLA MACHFACILITY TYPE:
740
ADDRESS:23235 CAVANAUGH RD.TELEPHONE:
(949) 716-1516
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mayla MachTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver and LPA explained the nature of the visit. Mayla Mach, Administrator arrived shortly after and met with LPA.

LPA Martinez began the tour of the inside and outside of the facility. There are six residents in care and there are no active covid-19 cases in facility. LPA observed one resident in living room watching TV and remainder of residents in their bedrooms. All residents appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperature daily and documenting the results. LPA observed the emergency disaster and evacuation plan. Facility has the back-up emergency food and water supply as well as PPE supplies. LPA toured the outside of the facility and observed a shaded seating area for resident’s enjoyment. LPA was informed that all residents and staff have had their covid booster shot. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed and approved by the Department on May 4, 2021.

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

This report was reviewed with Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
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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