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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004629
Report Date: 07/26/2021
Date Signed: 07/26/2021 12:33:36 PM

Document Has Been Signed on 07/26/2021 12:33 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 LAGUNA HILLSFACILITY NUMBER:
306004629
ADMINISTRATOR:BENIGNO BULANADIFACILITY TYPE:
740
ADDRESS:24961 SOUTHPORT STREETTELEPHONE:
(949) 683-8736
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 6DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Herminia Zuehl, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA arrived at facility was greeted at the door by Administrator and granted entry. LPA met with Administrator and explained the nature of the visit.

LPA immediately began the tour of the facility. The facility currently has 6 residents in care. LPA observed residents in dinning room having lunch. All residents appeared happy and well taken care of. Facility upon inspection appeared clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the visitors, staff and residents. At 11:33am LPA tested the hot water temperature in bathrooms which are used by the residents. The hot water temperature was measured at 113.7 Fahrenheit degrees. LPA observed facility has covid precautionary postings through out the facility as well as all required Department postings. Facility has an active covid-19 prevention plan in place for the safety of all the residents in care. LPA observed ample of emergency food and water as well. First aid kits are stored with medication. LPA observed facility has PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place in all residents bedrooms, through out the facility, and in all common spaces. LPA toured the outside of the facility and observed a shaded outside space for resident’s enjoyment. The area is used for outdoor visitation as well. Facility has a plan for covid testing residents and staff as needed. Facility has a plan for isolation as needed.

Based on the observations 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 Administrator and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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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