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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005441
Report Date: 09/20/2021
Date Signed: 09/20/2021 12:36:44 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/20/2021 12:36 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:FOUNTAIN VALLEY SENIOR HOMESFACILITY NUMBER:
306005441
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:18561 SANTA ISADORATELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Uldarico "Rico" Almiranez, Licensee/Administrator and Conrado Caniga, Caregiver.TIME COMPLETED:
12:07 PM
NARRATIVE
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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 and granted entry into the facility by caregiver Conrado Caniga and explained the nature of the visit. Licensee/Administrator Almiranez arrived shortly after. This facility is licensed to provide services to age range 60 and over, approved for 6 Non Ambulatory Residents, of which 1 may be bedridden, and has a hospice waiver for four (4) residents. Licensee/Administrator has an active Administrator Certificate with expiration date of 04/10/2022.

On or about 9:06am, LPA Quiroz along with Caregiver Caniga toured the inside and outside of facility. On or about 9:32am, LPA Quiroz toured the inside and outside of the facility with Licensee/Administrator Almiranez. There are five residents in care and there are no active COVID-19 cases. LPA Quiroz observed one resident in living-room area resting, and four residents in their bedrooms resting. All residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components.

LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area For resident’s enjoyment. Facility has completed the LIC808 Mitigation plan, which was approved by LPA Kimberly Lyman on 8/24/2021.

CONTINUED ON NEXT PAGE...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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Document Has Been Signed on 09/20/2021 12:36 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 09/20/2021 at 10:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FOUNTAIN VALLEY SENIOR HOMES
FACILITY NUMBER: 306005441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2021
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care (87465)(h)(2): Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by: At 9:39am, LPA
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Licensee/Administrator Almiranez indicated "I should have a box for medication that goes in refrigerator. I purchased one already." LPA Quiroz observed Caregiver Conrado Caniga place R1's Humulin N Kwin Pen Insulin suspension in locked boxed and placed it inside refrigerator.
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Quiroz observed R1's Humulin N Kwin pen insulin suspension unlocked being stored on second shelf on side of refrigerator. This poses an immediate risk for residents in care.
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Licensee/Almiranez agreed to provide medication training, but not limited to medication requiring refrigerator storage by 9/24/2021.
Type B
09/24/2021
Section Cited
CCR87303(a)

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Maintenance & Operation 87303(a):The facility shall be clean,safe,sanitary and in good repair at all times...for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: At 9:10am, LPA Quiroz observed broken/ripped screen door leading
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Correction made on the following: Caregiver Campopanes cleaned spider webs, dust on top of refrigerator and pantry during today's visit. Licensee Almiranez agreed to repair screen door leading to patio and R2's bedroom, repair lock in disinfectant drawer, and repair hole on door leading to garage area.
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to patio and R2's bedroom, spider webs throughout facility, mold on 2 shower curtain, dust on top of refrigerator and in pantry, unlocked disinfectants, broken lock where disinfectants are stored and hole on garage door leading to garage area. This poses a potential risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2021 12:36 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 09/20/2021 at 11:01 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FOUNTAIN VALLEY SENIOR HOMES
FACILITY NUMBER: 306005441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited
CCR
87705(5)

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Care of Persons with Dementia (5): Each resident with dementia shall have an annual medical assessment as specified in Section 87458,...reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.This requirement was not met as evidence by:
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Licensee/Administrator Almiranez will call and schedule for an annual and will provide CCL with a copy of current physician report for R2 by 9/30/2021.
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During today's visit, at 10:50am, LPA Quiroz observed R2's last physician report was completed on 2/22/2019. This poses a potential risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


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: FOUNTAIN VALLEY SENIOR HOMES
FACILITY NUMBER: 306005441
VISIT DATE: 09/20/2021
NARRATIVE
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Based on the observation made during today’s visit, the following deficiencies (listed on the LIC809-D attached) were observed and are being cited per Title 22, Division 6, of the California Code of Regulations.

This report was reviewed with Licensee/Administrator Almiranez, deficiencies and appeal rights were discussed with Licensee/Administrator Almiranez, and a copy of this report, LIC 809-D, Appeal rights and LIC 9102 Technical Assistance was provided to Licensee/Administrator Almiranez at exit.


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

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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