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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004547
Report Date: 07/15/2021
Date Signed: 07/15/2021 02:05:36 PM

Document Has Been Signed on 07/15/2021 02:05 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:PACIFIC SHORES OF LAKE FORESTFACILITY NUMBER:
306004547
ADMINISTRATOR:BENIGNO BULANADIFACILITY TYPE:
740
ADDRESS:21521 MORESBY WAYTELEPHONE:
(949) 716-8903
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Amy Zuehl and Alona SalazarTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Alona Salazar and explained the reason for the visit. Licensee Amy Zuehl arrived during the visit.

At 8:45 AM, LPA toured the facility with Licensee Zuehl. Facility has 6 residents during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Hand washing signs are posted in the restrooms. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. Facility has completed the mitigation plan and is pending approval. LPA observed adequate emergency food supply as well as the first aid kit which contained all required items. Facility has gloves, gown, sanitizer, and masks on site. LPA toured the outside grounds and observed ample shaded outside visitation areas. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed select resident files and all contained required documentation including updated emergency information.

LPA consulted with Licensee regarding the importance of maintaining ample supply of emergency water as well as the importance of keeping an adequate supply of PPE at the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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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