306005986-1-13-2022-22-AS-RMAZ-C9WRDQ-20211221115619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005986
Report Date: 12/21/2021
Date Signed: 01/13/2022 10:18:48 AM

Document Has Been Signed on 01/13/2022 10:18 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:	ACTIVCARE LAGUNA HILLS		FACILITY NUMBER:	306005986
ADMINISTRATOR:	SHETTER, TODD A.		FACILITY TYPE:	740
ADDRESS:	25200 PASEO DE ALICIA		TELEPHONE:	(858) 565-4424
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 72		CENSUS: 0	DATE:	12/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Todd Shetter, Director Patricia Miller, Executive Director		TIME COMPLETED:	12:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation inspection. LPA arrived at the facility was greeted by applicant and granted entry. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (72) capacity, (0) ambulatory, (55) non-ambulatory, and (17) bedridden clients was submitted to CCL on 03/29/2021. Structure: The facility is a beige stucco structure with brown trim one-story facility with 10 bedrooms in wing 100, 9 bedrooms in wing 200, 13 bedrooms in wing 300, 11 bedrooms in wing 400, 4 central shower bathrooms, 2 dining rooms/activities room, 1 kitchen, 1 medication room, 1 nurses office, 1 beauty/barber shop and 1 laundry room. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There are 2 courtyards with exit ways in each with seating area for residents throughout. Signal system: Delayed Egress System in place. Signal system for pendants/call buttons that are in place. Bedrooms Residents: Bedrooms are apartment style which will accommodate 55 non-ambulatory and 17 bedridden. Bedrooms will be for both private rooms and shared rooms. Bedrooms Staff: No live in staff bedrooms. Continued on LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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: ACTIVCARE LAGUNA HILLS	FACILITY NUMBER: 306005986
	VISIT DATE: 12/21/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bathrooms:
All bathrooms have a working toilet, wash basin, bath-tub/shower. Each bedroom has their own bathroom and there are 4 centralized showers throughout the facility.

Linens & Hygiene Supplies:
Adequate supply of linen stored in facility storage closet located in wing 100.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are to be stored in the kitchen. Food delivery will be done once a week.

Smoke Detectors:
Smoke detectors/carbon monoxide alert systems are hardwired and sprinkler system were tested and found operational.

Appliances:
Gas burner stove, ovens, refrigerator/freezer, dish washer, 2 washers, and 2 dryers are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents are stored and locked in a storage closet.

Water Temperature:
Tested and recorded the water temperature measures 106.4 – 109.9 Fahrenheit degrees in all restrooms.
Continued on LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 2 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: ACTIVCARE LAGUNA HILLS	FACILITY NUMBER: 306005986
	VISIT DATE: 12/21/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Medications, First-Aid Kit & Book:
Medication stored in medication room in a med cart with a lock inaccessible to residents. First aid is stored in medication room, kitchen and throughout the facility in common areas.

Clients & Staff Files:
Records for residents and staff will be kept locked in nurses office.

Pool/Jacuzzi & Pets:
No bodies of water in facility.

Fire Extinguisher:
Mounted throughout the facility dated June 26, 2021.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Fire clearance:
Was approved on November 08, 2021.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, mail, fax or email.

All items reviewed during the visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor.
Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3