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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004198
Report Date: 08/13/2021
Date Signed: 08/13/2021 03:50:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/13/2021 03:50 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:VERSA-CARE HOME IFACILITY NUMBER:
306004198
ADMINISTRATOR:CHERRY AGUILAFACILITY TYPE:
740
ADDRESS:1576 SPRUCE UNIT ATELEPHONE:
(714) 646-9217
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 5DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cherry AguilaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Joselito Gamas. The focus of the visit was Infection Control. Administrator Cherry Aguila was contacted and arrived a short time after LPA.
During the visit LPA toured the facility with Joselito Gamas and the following was observed:

Covid signage was posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was made available. Facility has required Department postings. LPA observed a copy of Administrator Certificate for Cherry Aguila expires on 11/11/2020. Ms. Aguila stated she is awaiting her new certificate as there were issues with her course documentation. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed resting in their rooms. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA did not observe emergency food and water supply. Ms. Aguila stated that she would obtain emergency supplies. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff at all times. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as PIN 21-32-ASC Updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Cherry Aguila.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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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