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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004750
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:18:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/07/2022 03:18 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:EASTWOOD CARE HOMEFACILITY NUMBER:
306004750
ADMINISTRATOR:ANNA MALLARIFACILITY TYPE:
740
ADDRESS:8426 CHOPIN DRIVETELEPHONE:
(714) 735-9004
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 5DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Paul Faeldo, Caregiver and Anna Mallari, Administrator (Via telephone)TIME COMPLETED:
03:33 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, COVID-19 screened and granted entry into the facility by Caregiver Paul Faeldo. LPA Rosie Quiroz called and spoke to Administrator Anna Mallari via telephone and discussed purpose for today's visit. Facility indicated screening all incoming visitors prior to entering the facility. Facility is a Level 4 facility, and is licensed to provide services to a capacity of (6) developmentally disabled clients age range 60 and over, (5) five Non Ambulatory clients and (1) one bedridden client in Room #5 only. Facility has a hospice waiver for (2) two clients. Facility is not providing hospice care services at this time. Administrator Anna Mallari has a current Administrator certificate with expiration date of December 26, 2023.

On or about 1:38 pm, LPA Rosie Quiroz along with Caregiver Paul Faeldo began the tour of the inside and outside of the facility. There are (5) five clients in care and there are no active COVID-19 cases in the facility. During today's facility inspection, LPA Quiroz observed Client 1 (C1) and Client 3 (C3) in the living-room relaxing watching television supervised by caregiver. LPA Quiroz observed Client 2 (C2) in his bedroom relaxing. LPA Quiroz interacted and interviewed with clients during today's visit. On or about 2:30pm, Client 5 (C5) arrived to Facility from his day program. Four of five clients present during today's visit appeared to be clean and well taken care of.

LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 75 degrees Fahrenheit.

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within normal limits. Five of five client's bedrooms appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Continued on next page...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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: EASTWOOD CARE HOME
FACILITY NUMBER: 306004750
VISIT DATE: 06/07/2022
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Facility has a supply of emergency food, water and PPE in closet in main hallway and kitchen area readily available for staff and clients. LPA Quiroz toured the outside of the facility and observed seating and shaded area for clients and visitors enjoyment in backyard area.

The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on March 26, 2021. LPA Micah Martinez reviewed and approved LIC 808 Mitigation Plan on March 26, 2021.

LPA Quiroz was informed that all clients and staff have had their COVID-19 vaccinations and first Booster. Facility indicated to be recording clients temperatures daily.

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. Advisory Note-Technical assistance observed during today's date (SEE LIC 9102 TA)

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

This report was reviewed with Caregiver Paul Faeldo, and a copy of this report and LIC 811 Confidential Names were provided at exit.

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

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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