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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005977
Report Date: 01/27/2025
Date Signed: 01/27/2025 03:18:35 PM

Document Has Been Signed on 01/27/2025 03:18 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:FOUNTAIN VIEW CARE HOMEFACILITY NUMBER:
306005977
ADMINISTRATOR/
DIRECTOR:		ORTIZ-LUIS, VIVIAN ANNFACILITY TYPE:
740
ADDRESS:17688 SAN FRANCISCO STTELEPHONE:
(626) 272-5906
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Elvira Bathan
Geronima Cubacub		TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff and LPA explained the nature of the visit. There are four residents at the facility and there is two residents receiving hospice services currently.

LPA began the tour of the inside and outside of the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage in a refrigerator located in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet in the kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 109.5 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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: FOUNTAIN VIEW CARE HOME
FACILITY NUMBER: 306005977
VISIT DATE: 01/27/2025
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seating areas for residents’ enjoyment. LPA observed a fire extinguisher with service date of December 26, 2024, in kitchen. LPA began review of records. LPA reviewed two resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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