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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005829
Report Date: 10/11/2021
Date Signed: 10/11/2021 01:04:27 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/11/2021 01:04 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:MT. SHERROD HOME, LLC.FACILITY NUMBER:
306005829
ADMINISTRATOR:LASALA-DOAN, GERALDINEFACILITY TYPE:
740
ADDRESS:16550 MT. SHERROD CIRCLETELEPHONE:
(714) 839-4417
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Vivian Ortiz-Luis, Caregiver, Connie Vallesteros, Caregiver, Geraldine Doan, Licensee/AdministratorTIME COMPLETED:
01:10 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 Quiroz was greeted and granted entry into the facility by caregiver Consolacion Vallesteros and explained the nature of the visit. LPA Quiroz met with Caregiver Vivian Ortiz-Luis. During today's visit, LPA Quiroz called and spoke to Licensee/Administrator (L/AD) Geraldine Doan via telephone who also arrived shortly after.

This facility is licensed to provide services to residents age range 60 and over, 6 Non-Ambulatory Residents of which 1 (one) may be bedridden and has a hospice waiver for six (6) residents. L/AD Geraldine Doan has an Administrator Certificate with expiration date of 09/27/2022.

On or about 12:05pm LPA Quiroz along with Caregiver Ortiz-Luis toured the inside and outside of facility. Two staff working at facility were observed to be wearing face masks upon arrival to facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed three residents in dining-room area eating lunch in the dining-room, one resident watching television in living-room, and one resident in their bedroom resting. Five of five residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan, L/AD Doan will update and re submit updated LIC 808 Mitigation Plan to CCL by COB 10/12/2021.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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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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: MT. SHERROD HOME, LLC.
FACILITY NUMBER: 306005829
VISIT DATE: 10/11/2021
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During today's inspection visit, LPA Quiroz reviewed five of five resident records. L/AD Geraldine Doan indicated "all residents and staff at facility are fully vaccinated for COVID-19."

Based on the observation 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 L/AD Geraldine Doan, and a copy of this report was provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
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