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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005800
Report Date: 02/11/2022
Date Signed: 02/11/2022 10:38:52 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/11/2022 10:38 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:FOUNTAIN GARDEN GUEST HOMEFACILITY NUMBER:
306005800
ADMINISTRATOR:LUU, CHI VFACILITY TYPE:
740
ADDRESS:16803 MAPLE ST.TELEPHONE:
(714) 602-1515
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Telma Rivera, Caregiver
Chi Luu (Rex), Administrator		TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA arrived at facility and was greeted and granted entry by Telma, caregiver after being screened for COVID-19. Staff called administrator. LPA explained the nature of the visit and conducted it with the present caregiver. Administrator Chi Luu arrived later and was explained the purpose of the visit as well.

At approximately 10:00am, LPA accompanied by caregiver began the tour of the facility. There are currently 5 residents in care including one resident on hospice. Some of the residents are observed relaxing in the common area and appear well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed no check-in station at the main entry of the facility, however visitors are observed being temperature screened upon entry. Facility is taking temperatures on a daily basis and documenting the results. LPA observed the facility has COVID-19 Precautions posters, all required department postings. Hand washing is being promoted and signs will be posted throughout the facility. LPA observed the emergency food supply and water. Facility has a supply of PPE stored in the attached garage. LPA toured the outside of the facility and observed outdoor seating for client’s enjoyment. Outdoor space is free of debris and well-maintained. Facility bedrooms are both shared and single occupancy. All bedrooms were observed to have all required components. Bathrooms are equipped with grab bars. The facility has completed the LIC808 Mitigation Plan, LPA Rosie Quiroz reviewed and approved the plan on today’s visit. LPA Rosie Quiroz emailed the signed and approved plan to the Administrator for their records.

Based on the observations 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 facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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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