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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004510
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:09:24 AM

Document Has Been Signed on 12/17/2024 11:09 AM - 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:LOVING CARE SENIOR HOMEFACILITY NUMBER:
306004510
ADMINISTRATOR/
DIRECTOR:
MAI T. NGUYENFACILITY TYPE:
740
ADDRESS:9435 KIWI CIRCLETELEPHONE:
(714) 867-8074
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Mai NguyenTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Mai Nguyen. Administrator Catherine Truong Administrator's certificate expires on August 24, 2025. Facility is licensed for 6 non-ambulatory residents and a hospice waiver for 2. Facility is a single story home with 5 bedrooms, 2 bathrooms, kitchen, living room, dining room and a two car garage. LPA observed the fireplace in the living room is screened. LPA observed the PUB 475 poster (See Something, Say Something poster) is 8 1/2 by 11 inches in size and is posted in the entry way of the facility. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day emergency food and water supply stored in the garage. Knives and cleaning supplies are kept locked under the kitchen sink. LPA observed the 4 burner gas stove lights unassisted. LPA observed medications are kept locked in a kitchen cabinet. LPA and the Administrator toured the resident rooms. LPA observed all 5 resident rooms are clean and organized. Smoke detectors/carbon monoxide detectors tested operational. LPA observed both bathrooms are clean and operational. Hot water measured 120.0 degrees Fahrenheit in both bathrooms. LPA observed a clean supply of linen stored in the hall closet. No obstacles or hazards observed inside of the facility. LPA and the Administrator toured the backyard. There are 3 storage sheds in the backyard. All 3 sheds are kept locked and used to store extra supplies and furniture. No bodies of water observed in the backyard. There is a covered patio with chairs to sit outside. The exit gate is operational. LPA reviewed 2 staff files. No discrepancies observed. Both staff members have the required training and CPR training. Both staff members are associated to the facility. LPA reviewed 6 resident files and medications, no discrepancies observed. LPA inspected the first aid kit. The first aid kit has all the required elements. The last emergency drill was conducted on November 23, 2024. The fire extinguisher in the living room is fully charged. No deficiencies are being cited as a result of this visit. LPA consulted with the Administrator concerning reporting requirements and restricted/prohibited conditions. An exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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