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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005845
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:53:47 AM

Document Has Been Signed on 02/17/2022 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:SANTA MARIANA CAREFACILITY NUMBER:
306005845
ADMINISTRATOR:LIMPIADO, GIDEONFACILITY TYPE:
740
ADDRESS:18676 SANTA MARIANATELEPHONE:
(949) 349-8708
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Roel Atanacio - CaregiverTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Santa Mariana Care. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Roel Atanacio. Caregivers Joselyn Arcelo and Sy Froilan were also present. The facility is licensed for 6 non-ambulatory residents. The facility also has an approved hospice waiver for 4 residents. There are currently 6 residents living in the facility. The facility has a written emergency disaster plan.


At 10:41 AM LPA Velazquez conducted a tour of the physical plant along with Caregiver Atanacio. The 1 story home consists of 4 resident bedrooms and 2 staff bedrooms with 3 bathrooms. The 6 residents in the facility appeared well-groomed and well cared-for. Caregiver Atanacio informed LPA Velazquez that there have not been any COVID-19 positive cases in the facility throughout the Pandemic. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails on the beds of some of the residents. LPA was informed that some of these residents were receiving hospice services. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 115.7 degrees Fahrenheit in the first bathroom, 108.6 degrees Fahrenheit in the second bathroom and at 116.7 degrees Fahrenheit in the third bathroom. LPA Velazquez inspected the kitchen with Caregiver Atanacio. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Toxins, sharps, and medications were locked and inaccessible to
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: SANTA MARIANA CARE
FACILITY NUMBER: 306005845
VISIT DATE: 02/17/2022
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residents. First aid kit was checked and found to be in order. The facility did have a First Aid guide which was noted to be outdated. LPA Velazquez advised Caregiver Atanacio to obtain an updated First Aid manual.

LPA Velazquez along with Caregiver Atanacio toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gate was operational. The auditory alarms were noted to be in operating condition except for the one in room 4 that emitted a weak signal which Caregiver Atanacio verified. Caregiver Atanacio proceeded to repair the auditory alarm during the visit and LPA Velazquez found it operational. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez did not observe bed rail orders for residents with half bed rails and one resident had an incomplete bed rail order which Caregiver Atanacio verified. LPA Velazquez printed and reviewed Title 22 Regulation Section 87608 Postural Supports with Caregiver Atanacio who acknowledged receiving a copy of said regulation.


There were no deficiencies cited during this Required 1 Year inspection. An exit interview was conducted with Caregiver Roel Atanacio and a copy of this report and a copy of the LIC 9102 was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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