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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005500
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:40:50 PM

Document Has Been Signed on 05/23/2022 04:40 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:CARE JULIET 1FACILITY NUMBER:
306005500
ADMINISTRATOR:DEL ROSARIO, LESTERFACILITY TYPE:
740
ADDRESS:479 S WELLINGTON RDTELEPHONE:
(209) 914-1153
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 6DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Julieta Cervania, Caregiver and Lester DelRosario, AdministratorTIME COMPLETED:
04:55 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 and granted entry into the facility by Caregiver (CG) Julieta Cervania. LPA Rosie Quiroz explained the nature of the visit. Administrator Lester DelRosario arrived shortly after. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 6 Non Ambulatory residents, and has a Hospice Waiver for 6 residents. Facility is currently providing services to zero (0) residents on hospice and three (3) resident on Assisted Living Waiver program. Administrator Lester DelRosario has a current Administrator certificate with expiration date of June 16, 2022.
On or about 3:36pm, LPA Rosie Quiroz along with (CG) Julieta Cervania began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed Resident 1 and Resident 2 in living room area resting, Resident 3 and Resident 4 in front porch area conversing and Resident 5 and Resident 6 in their bedrooms watching television. LPA Quiroz interacted and interviewed with residents during today's visit. Six of six residents 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 110-110.2 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating area for residents and visitor's enjoyment in backyard and front porch area. The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on March 05, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated March 05, 2021.
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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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: CARE JULIET 1
FACILITY NUMBER: 306005500
VISIT DATE: 05/23/2022
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 LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and first Booster and will be speaking to resident's families and pharmacy about second booster vaccination. Facility indicated to be recording resident's temperatures twice daily.

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

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. Technical Violation LIC 9102TV for (87705)(5) was issued on today's date, and discussed with (AD) Lester Del Rosario.

This report was reviewed with (AD) Lester DelRosario, and a copy of this report, LIC 9102TV and LIC 811 Confidential Names were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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