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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002969
Report Date: 08/27/2021
Date Signed: 08/27/2021 02:16:00 PM

Document Has Been Signed on 08/27/2021 02:16 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:AVONDALE FAMILY CARE HOME IIFACILITY NUMBER:
306002969
ADMINISTRATOR:MARIA TERESA NAVARRAFACILITY TYPE:
740
ADDRESS:3129 INCLINADOTELEPHONE:
(949) 429-8190
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: 6DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Ronnie Lopez and Tess NavarraTIME COMPLETED:
10:31 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Ronnie Lopez and explained the reason for the visit. Administrator Tess Navarra arrived during the visit. Administrator Tess Navarra has an administrator certificate expiring on 04/14/2023.

At 9:35 AM, LPA toured the facility with Administrator Navarra. Facility has 6 residents in care during today's visit. One resident is bedridden and facility has bedridden fire clearance. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. LPA observed a generator on-site. LPA toured the outside grounds and observed multiple shaded outside visitation areas. LPA observed a fenced pool in the backyard. Exit gates are unlocked and self latching. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six resident files during the visit and all files are up to date including emergency information. Most residents and all staff are vaccinated for Covid-19.

LPA consulted with Administrator regarding the size of the "Let Us Know" poster. Administrator to enlarge poster and re-post.
No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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