306003937-12-20-2024-22-AS-ARJR-DC5W3X-20241220155638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003937
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:56:43 PM

Document Has Been Signed on 12/20/2024 03:56 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	LOS TIEMPOS SENIOR LIVING		FACILITY NUMBER:	306003937
ADMINISTRATOR/ DIRECTOR:	ROSA FIGUEROA		FACILITY TYPE:	740
ADDRESS:	17935 LOS TIEMPOS STREET		TELEPHONE:	(714) 964-6310
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 6	DATE:	12/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	Isabel Rosales-Caregiver, Rosa Figueroa-Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:12 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Brandon Lopez conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Caregiver Isabel Rosales. Administrator (AD) Rosa Figueroa arrived shortly after.

For today’s visit, LPA observed a total of six residents in care and two staff members on duty.

During today's visit LPAs observed the AD certificate for AD Rosa Figueroa which expires on September 08, 2025.

LPAs toured the interior and exterior portions of the facility with AD Figueroa. The facility is a one story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of five bedrooms, of which five are resident bedrooms. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of four restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 110.4-112.6 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the dining room, one in the activities/sun room and one in the garage.

During today's visit LPAs observed as the residents were eating chicken, salad and spaghetti for lunch.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOS TIEMPOS SENIOR LIVING	FACILITY NUMBER: 306003937
	VISIT DATE: 12/20/2024

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LPAs observed the emergency disaster and evacuation plan which is located by the dining room. Facility had back-up emergency food and water supply.

LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care. The medication is locked in a closet by the residents' bedroom hallway. The toxins are locked in the garage.

For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard. No bodies of water were observed.

LPAs reviewed six resident files and three staff files. Two of six resident files did not include a pre-admission appraisal; a Deficiency was issued today. LPAs interviewed residents and staff present.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

LPA advised AD Figueroa to use the general email address:

CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Figueroa.

A copy of this report and Appeal Rights were provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2024 03:56 PM - It Cannot Be Edited

Created By: Alvaro Ramirez Jr. On 12/20/2024 at 03:10 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOS TIEMPOS SENIOR LIVING	FACILITY NUMBER: 306003937
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that two of six resident records did not have a pre-admission appraisal.
	POC Due Date: 01/01/2025
	Plan of Correction
1 2 3 4	Licensee to complete a pre-admission appraisal for Resident 1 (R1) and R2 and email proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Sheila Santos

LICENSING EVALUATOR NAME:

Alvaro Ramirez Jr.

LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

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