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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005499
Report Date: 11/03/2021
Date Signed: 11/03/2021 11:59:28 AM

Document Has Been Signed on 11/03/2021 11:59 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:SIGNATURE RESIDENCE, INC. THEFACILITY NUMBER:
306005499
ADMINISTRATOR:FARIS, KOLALEHFACILITY TYPE:
740
ADDRESS:2727 WAVECREST DRTELEPHONE:
(949) 220-1412
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY: 6CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kolaleh FarisTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Amilcar Miranda Sales and Darioush Vohoumani. Administrator Kolaleh Faris was contacted and arrived a short time later. The focus of the visit was Infection Control. LPAs toured the facility with Mr. Miranda Salas and the following was observed:

Covid signs were posted at the front entrance of facility with a sanitization station. LPAs temperatures were taken upon arrival and a sign in sheet was available. Facility has required Department postings. Administrator Certificate for Kolaleh Faris expires on 4/10/22. Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were resting upon arrival and lunch will be served 12 to 1215pm. Social distancing and masks for staff were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured storage for medication and files. All residents have at least a 30 day supply of medications.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. As well as PIN 21-32.1- ASC Updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Kolaleh Faris.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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