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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004732
Report Date:
07/01/2021
Date Signed:
07/01/2021 04:55:56 PM
Document Has Been Signed on
07/01/2021 04:55 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:
ADELANTO COVENANT CARE, LLC
FACILITY NUMBER:
306004732
ADMINISTRATOR:
JOSEPH A. CARDELLA
FACILITY TYPE:
740
ADDRESS:
24901 ADELANTO DRIVE
TELEPHONE:
(310) 595-4482
CITY:
LAGUNA NIGUEL
STATE:
CA
ZIP CODE:
92677
CAPACITY:
6
CENSUS:
6
DATE:
07/01/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
03:01 PM
MET WITH:
Josephine Anzia
TIME COMPLETED:
05:12 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with staff Josephine Anzia and explained the reason for the visit. LPA toured the facility. Total of 2 staff were at the facility during the visit. Facility has 6 residents in care during today's visit. Facility is a single story house with an attached garage which is used for storage. Facility has 7 bedrooms and 5 bathrooms. One room is for caregivers. LPA observed residents relaxing in the living room watching TV. Facility is clean and organized. LPA observed no obstacles or hazards in the facility. All residents rooms had the required elements and were clean and organized. Restrooms were clean and operational. Hot water measured 115 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors are operational. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station next to the facility entrance. Facility utilizes a visitor sign in sheet. Facility has covid 19 precaution postings as well as all required department postings. Administrator Joseph A. Cardella has an administrator certificate that expires on 03/12/2022. Facility mitigation plan (LIC 808) is pending approval. LPA observed adequate emergency food and water as well as the first aid kit. Exit gates are both unlocked and operational. LPA did not observe any hazards or obstructions in the outside grounds. LPA observed the locked medication storage area. Facility has ample supply of PPE stored in the garage. Facility has an ample supply of cleaning products. 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 consulted with the staff concerning Covid-19 precautions. An exit interview was conducted with staff Josephine Anzia and a copy of the report provided.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/01/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2021
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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