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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005736
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:38:53 PM

Document Has Been Signed on 03/21/2024 12:38 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: 4DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Tina Menendez, Administrator and Christine Lezsak, House ManagerTIME COMPLETED:
12:40 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 was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz met with Administrator (AD) Tina Menendez and House Manager (CM) Christine Lezsak and discussed purpose of today's visit.
This is a a Residential Care Facility for the Elderly, licensed to provide services to age range 60 and over, approved for capacity of (6) six resident which (5) five are Non-Ambulatory and (1) one Ambulatory; Bedroom 5 approved for Ambulatory only; Rooms 1-4 approved for Non-Ambulatory; Hospice waiver approved for 2 hospice residents. There are currently four (4) residents in care at this time, of which (1) one is receiving hospice care services. There are no active COVID-19 cases in the facility at this time.
AD Tina Menendez has an Administrator certificate with expiration date of March 22, 2024. AD Menendez indicated currently in process of renewing Administrator certificate, and agreed to submit copy of renewal to Community Care Licensing upon completion.
LPA Quiroz along with (AD) Menendez and (HM) Lezsak toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed 2 of 4 Residents in the living room area watching television with staff supervision and 2 of 4 residents in their bedrooms resting with staff conducting frequent round checks as needed. LPA Quiroz interacted and interviewed with Caregivers and residents during today's visit.
LPA Quiroz inspected resident's bedrooms and bathrooms. The water temperature in resident's bathrooms were recorded to be within normal limits. LPA Quiroz inspected resident's bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has supply of emergency food, water and PPE in the garage area readily available for staff and residents in care. 4 of 4 Fire extinguishers observed last serviced on March 1,2024. LPA Quiroz observed functional and operational washer and dryer in the laundry room area. Medications, sharps and disinfectants were observed to be locked and secured. CONTINUED ON LIC 809-C PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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: ELD HEALTHCARE
FACILITY NUMBER: 306005736
VISIT DATE: 03/21/2024
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CONTINUED...LPA Quiroz toured the outside of the facility and observed seating and shaded area in the backyard and front porch area for residents and visitor's enjoyment.
CONTINUED...LPA Quiroz reviewed 4 of 4 resident records and 7 of 7 personnel files.

No citations issued during today's visit.

During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control. An exit interview was conducted with (AD) Menendez and (HM) Lezsak, and a copy of this report, LIC 858- Client/Resident's records review, LIC 811- Confidential names, were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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