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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005201
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:33:55 AM

Document Has Been Signed on 11/01/2022 11:33 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PRINCEVILLE-BOLSA CHICAFACILITY NUMBER:
306005201
ADMINISTRATOR:OLIVER, MYRIAMFACILITY TYPE:
740
ADDRESS:5191 VALLECITO AVETELEPHONE:
(714) 622-5337
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 5DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Facility Administrator - Karl PaduaTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) who checked temperature prior to entering facility. During the visit, there were a total of 2 staff members on duty. As of 11/1/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed in the facility hallway. LPA De Perio observed the Administrator's Certificate for Karl Padua which expires on 11/16/22.

LPA De Perio toured the interior and exterior portions of the facility with AD Padua. The facility is a single level structure and is licensed for residents 50 years old and over, of which 6 may be non-ambulatory, and 0 may be bedridden and a hospice waiver is in place for 3 . For this visit, there are a total of 5 residents in care, of which 1 is on hospice, and 0 bedridden. There are a total of 6 bedrooms, of which 4 are private resident rooms, 1 shared resident room and 1 room designated for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which 1 is for staff and 2 are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 106.9 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care and located in a kitchen drawer. Fire extinguisher was charged, mounted and located in the kitchen.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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: PRINCEVILLE-BOLSA CHICA
FACILITY NUMBER: 306005201
VISIT DATE: 11/01/2022
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LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked and located in a kitchen drawer. Toxins were also observed to be locked and inaccessible to residents in care, and located in the garage, of which garage remains locked at all times.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 exit gates in the backyard, which were self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Padua. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Padua to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Padua.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Padua to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Padua and a copy of this report and copies of the regulations discussed were provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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