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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005754
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:09:48 AM

Document Has Been Signed on 08/29/2024 11:09 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MILES PLACE OF FOUNTAIN VALLEYFACILITY NUMBER:
306005754
ADMINISTRATOR/
DIRECTOR:		AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:18667 SAN FELIPE STREETTELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mark Cruz- Administrator TIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Amy Valencia who granted LPA entry into the facility. At approximately 10:18 AM the Administrator Mark Cruz arrived and assisted with inspection.

The facility is a Residential Care Elderly (RCFE) licensed for a capacity of (6) non-ambulatory residents ages 60 and up. LPA conducted general overall inspection, which included, but was not limited to,the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

The hot water temperature tested within regulation at 104-124 degrees F. in both bathrooms. The facility is equipped with operating smoke detectors, carbon monoxide detectors and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked inaccessible to clients in the kitchen cabinet. There was a designated place for client/staff files. Overall, the facility appeared to be clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MILES PLACE OF FOUNTAIN VALLEY
FACILITY NUMBER: 306005754
VISIT DATE: 08/29/2024
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Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians.

LPA also reviewed two (2) staff files for First Aid/CPR certification, training's, and health screenings and appeared to be current.

Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Administrator Mark Cruz at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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