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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005829
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:21:45 AM

Document Has Been Signed on 10/30/2024 11:21 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:MT. SHERROD HOME, LLC.FACILITY NUMBER:
306005829
ADMINISTRATOR/
DIRECTOR:		VIVIAN LUIS-ORTIZFACILITY TYPE:
740
ADDRESS:16550 MT. SHERROD CIRCLETELEPHONE:
(714) 839-4417
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Geraldine Lasala Doan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1. During today’s visit, LPA met with Geraldine Lasala Doan, Administrator (AD).

The facility is a single story building with an approved fire clearance of six non-ambulatory residents of which one may be bedridden and is approved with a hospice waiver for six residents. The facility currently has a census of six residents in care with three on hospice. There are five private bedrooms and one shared bedroom.

At 8:40 AM LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured 119.4 degrees Fahrenheit in both bathrooms and all smoke and carbon monoxide detectors were operational. The fire extinguishers are charged and were serviced on August 5, 2024. The facility’s last fire drill was conducted on September 13, 2024.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications at 10 AM. The First Aid Kit had all of the required elements with a FIrst Aid Manual. Per review medications are being given as prescribed.

At 10:30 AM LPA observed three residents doing chair exercises with Staff #2. The outdoor area had a shaded area and all outdoor exit gates were self-closing. There were no obstacles or hazards observed.

(Continued on LIC 809)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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: MT. SHERROD HOME, LLC.
FACILITY NUMBER: 306005829
VISIT DATE: 10/30/2024
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(Continued from LIC 809)

LPA reviewed three of three staff training and fingerprint records and a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a pending renewal administrator certificate which will expire on August 16, 2026.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Staff #1 and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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