<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005736
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:37:38 PM

Document Has Been Signed on 03/30/2022 03:37 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:ELD HEALTHCAREFACILITY NUMBER:
306005736
ADMINISTRATOR:TINA MENENDEZFACILITY TYPE:
740
ADDRESS:985 NORTH SHAFFER STREETTELEPHONE:
(949) 375-6635
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 3DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Tina MenedezTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was granted entry into the facility by Caregiver Vicky Bermudez. Administrator Tina Menedez arrived shortly after and reason for the visit was shared. Caregiver Bermudez confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility.

LPA observed required Department posting on COVID-19 precautions at entrance of facility and throughout. There is an electronic sign-in procedure in place and hand sanitizer for use. LPA observed staff were wearing face masks. The facility has an approved Mitigation Plan on file with CCLD. Two residents were present in the facility during today's visit. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA toured resident rooms, all rooms were within regulations. Restrooms observed contained hand washing soap, toilet paper and paper towels. The proper hand washing signs were posted in the restrooms. Facility has operating smoke and carbon monoxide detectors. Facility's Fire Extinguisher was charged. LPA observed a copy of Administrators Certificate which expired on 03/22/2022. AD has completed requirements for renewal. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted, and a medication cart for resident's medication. Staff and Residents files are locked in an office cabinet. Facility has 30 days supply of medications for the residents.

Based on observations made during today’s inspection, no deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with Administrators and a copy will be emailed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1