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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005754
Report Date: 06/14/2021
Date Signed: 06/14/2021 11:53:06 AM

Document Has Been Signed on 06/14/2021 11:53 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:MILES PLACE OF FOUNTAIN VALLEYFACILITY NUMBER:
306005754
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:18667 SAN FELIPE STREETTELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mark Ryan CruzTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required/annual visit. LPA was greeted at the door by caregiver and granted entry into the facility. Administrator Mark Cruz arrived shortly after. LPA met with Administrator and explained the nature of today’s visit.

LPA accompanied by caregiver toured the facility physical plant. Facility currently has 5 residents in care during today’s visit. Upon entry LPA observed check in station for temperature checks and sign in process. LPA observed four residents in living room watching TV and all residents appeared happy and well taken care of. Facility appears to be clean and sanitary. Facility screens all visitors upon entry to facility, it was observed facility has check in station by entry door of facility. Facility utilizes a sign in sheet as well as a temperature check. Facility takes residents and staff temperature daily check daily and documents checks. Facility has covid precautionary postings at entry door and through out the facility, all required department posting were observed as well. LPA reviewed the mitigation plan and was given a copy for records. LPA observed to be ample food and water as well as first aid kits though out the facility. Facility has sanitation stations spread out through out the common areas of the facility. There is a large covered patio area in the outside of the facility utilized for activities and visitations. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for covid testing residents and staff as well a plan for isolation as needed. Facility currently has 4 private bedrooms and 1 shared bedroom.

An exit interview was conducted with Administrator and a copy of this report was left at the facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2021
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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