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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004510
Report Date: 11/30/2021
Date Signed: 11/30/2021 04:12:22 PM

Document Has Been Signed on 11/30/2021 04:12 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:LOVING CARE SENIOR HOMEFACILITY NUMBER:
306004510
ADMINISTRATOR:MAI T. NGUYENFACILITY TYPE:
740
ADDRESS:9435 KIWI CIRCLETELEPHONE:
(714) 867-8074
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Mai Nguyen, AdministratorTIME COMPLETED:
04:27 PM
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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by caregiver Thinh Pham. LPA Quiroz called Licensee/Administrator (L/AD) Mai Nguyen and left voicemail and explained the nature of the visit via voicemail message. L/AD Mai Nguyen arrived during today's visit

This facility is licensed to provide services to 6 Non Ambulatory residents and has a hospice waiver for (2) residents. L/AD Mai Nguyen has an Administrator Certificate with expiration date of 7/23/2022.

On or about 3:20pm, LPA Quiroz reviewed 6 of 6 resident records.

On or about 3:42pm, LPA Quiroz along with L/AD Mai Nguyen toured the inside and outside of the facility. There are six (6)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed six (6) residents in living room area listening to music on television and interacting with staff. Six of six residents present in the facility appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. L/AD Mai Nguyen indicated facility is taking temperatures daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed ample seating area with tables and chairs for resident’s enjoyment in backyard area.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LOVING CARE SENIOR HOME
FACILITY NUMBER: 306004510
VISIT DATE: 11/30/2021
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CONTINUED...

Facility has completed the LIC 808 Mitigation plan dated 12/21/2020. The LIC 808 Mitigation Plan was approved by LPA Quiroz during today's visit.

During today's inspection visit, L/AD Mai Nguyen indicated "All staff and residents are fully vaccinated and have received booster for COVID-19." LPA Quiroz reviewed 6 of 6 resident's records during today's visit.

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 L/AD Mai Nguyen, and a copy of this report and LIC 811 were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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