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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004028
Report Date: 08/16/2024
Date Signed: 08/16/2024 10:10:01 PM

Document Has Been Signed on 08/16/2024 10:10 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:ARBOR VIEW IIFACILITY NUMBER:
306004028
ADMINISTRATOR/
DIRECTOR:		FISK, MARK & ERINFACILITY TYPE:
740
ADDRESS:25342 MAXIMUS STREETTELEPHONE:
(949) 295-9191
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Brigitte Fisk, Administrator
Mark Fisk, Administrator
Erin FIsk, Administrator		TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility administrator Brigitte Fisk at the facility. Administrators Mark and Erin Fisk were notified by phone and joined the visit at a later time.

During the inspection, LPA and facility caregiving staff conducted a tour of the physical plant and observed the following: The facility is a one story home with has four private rooms, one shared room and two shared bathrooms. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets.
The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently six residents admitted to the facility with four resident receiving hospice care at the time of the visit. Residents are observed to be clean and appear well taken care of. Three residents are observed to be relaxing in the facility's living room while the three others are observed in their bedrooms. Bathrooms faucets and toilets were operational and water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. The separate smoke and carbon monoxide detectors tested operational. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed six resident files and two staff files.

Based on the observations made during today’s inspection, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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Document Has Been Signed on 08/16/2024 10:10 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 08/16/2024 at 04:10 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: ARBOR VIEW II
FACILITY NUMBER: 306004028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, records reviewed and staff interview, the licensee did not comply with the section cited above as there are currently four resident receiving hospice care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee plans on applying for a hospice waiver for the full capacity of the facility. Application to be submitted before the plan of corrections due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
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