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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006057
Report Date: 12/19/2024
Date Signed: 12/19/2024 02:06:30 PM

Document Has Been Signed on 12/19/2024 02:06 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:SOLIVEN CARE HOMEFACILITY NUMBER:
306006057
ADMINISTRATOR/
DIRECTOR:
SOLIVEN, JOSELOLITOFACILITY TYPE:
740
ADDRESS:6710 SEQUOIA DR.TELEPHONE:
(714) 310-9293
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Irene Plascencia, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to finish the annual inspection. LPA arrived unannounced and met with Staff, Irene Plascencia. Administrator, Joselolito Soliven, arrived shortly after to assist with the visit. The initial inspection began on 12/9/24.

During the visit today, LPA conducted the remainder of domains from the CARE tools.
Staffing: The administrator's (Joselolito Soliven) certificate expired on 8/15/24, however, LPA verified that the renewal documents were received by the department. Staff employed are over the age of 18 and are fingerprint cleared. Per the administrator, there is backup staff if needed.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed the Administrator and 2 other staff files. There are sufficient annual training on file. CPR & First Aid certificates are current for all 3 staff.
Resident Records-Incident Reports: Resident files are maintained at the facility. LPA reviewed all 5 resident files and the documents are in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, and Resident rights. LPA issued a technical violation for the preadmission appraisal which was not found in their files.
Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted at the facility.
Incidental Medical & Dental: Medications are centrally stored and locked in the storage cabinet. All resident medications were reviewed and there were no discrepancies found.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are currently no residents on hospice.

No deficiencies were given, however, technical violations were issued. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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