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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005592
Report Date: 05/21/2021
Date Signed: 05/24/2021 07:32:41 AM

Document Has Been Signed on 05/24/2021 07:32 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:PRIMACARE HOME AT ROXBURYFACILITY NUMBER:
306005592
ADMINISTRATOR:LAPID, BEATRIZ SFACILITY TYPE:
740
ADDRESS:4662 ROXBURY DRTELEPHONE:
(949) 278-3215
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 6CENSUS: 3DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jasper Eagle and Beatriz and Roland LapidTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Jasper Eagle and explained the reason for the visit. Administrators Roland and Beatriz Lapid arrived during the visit.

At 12:43, LPA toured the facility with Caregiver Jasper Eagle. There are three residents in care during today's visit. Facility has no active covid cases and all have been vaccinated. Facility has all required department postings as well as an infection prevention posted outside front door. Facility takes all visitors temperatures and requests hand washing upon entry. Residents are screened for temperature daily and results documented. LPA observed all resident bedrooms and facility bathrooms are clean and sanitary. All restrooms have ample soap/ sanitizer. Facility has two outdoor visitation areas. LPA observed emergency food and water supply. Facility has completed the required mitigation plan. Facility has a plan for testing staff and residents for covid-19 as needed. LPA observed ample PPE in the facility.

During the visit, LPA consulted with Administrators on the importance of keeping ample water supply on the premises, posting hand washing signs in the restroom as well as ensuring PPE is accessible to staff..

No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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