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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005602
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:42:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/21/2021 01:42 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:NIKKI'S LOVING CARE HOMEFACILITY NUMBER:
306005602
ADMINISTRATOR:GIOVANI, NICOLEFACILITY TYPE:
740
ADDRESS:13642 FAIRMONT WAYTELEPHONE:
(714) 505-3258
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 3DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Cristina Radu, Administrator and Nicole Giovani Licensee/Administrator.TIME COMPLETED:
01:48 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 Ronnie Paulus and explained the nature of the visit. Licensee/Administrator (L/AD) Nicole Giovani and Administrator (AD) Cristina Radu arrived shortly after. This facility is licensed to provide services to 6 Non-Ambulatory Residents, and has a hospice waiver for two (2) residents. Administrator (AD) Cristina Radu has an Administrator Certificate with expiration date of 3/23/2022 and AD Nicole Giovani has an Administrator Certificate with an expiration date of 3/1/2022.

On or about 1:12pm LPA Quiroz along with AD Radu toured the inside and outside of facility. Staff working at facility were observed to be wearing face masks upon arrival to facility. There are currently three residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz interacted with residents in care. LPA Quiroz observed one resident in living-room area sitting on recliner chair resting watching television, and two residents in their bedrooms resting. Three of three 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 and appeared clean. 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 with table and chairs for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan and LPA Quiroz approved the plan dated 7/08/2021 on today’s visit.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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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: NIKKI'S LOVING CARE HOME
FACILITY NUMBER: 306005602
VISIT DATE: 09/21/2021
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During today's inspection visit, LPA Quiroz reviewed four of four resident records.

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.

This report was reviewed with Licensee/Administrator Nicole Giovani, and a copy of this report was provided to Licensee/Administrator Nicole Giovani at exit.

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

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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