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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006113
Report Date: 03/10/2025
Date Signed: 03/10/2025 03:57:38 PM

Document Has Been Signed on 03/10/2025 03:57 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:MILES PLACE OF FOUNTAIN VALLEY 2FACILITY NUMBER:
306006113
ADMINISTRATOR/
DIRECTOR:		AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:9367 SISKIN AVENUETELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mark Cruz - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On March 10, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced visit for the purpose of conducting an Annual Required-1 year inspection visit. LPA Bentley was greeted and granted entry by Caregiver (CG) Jovalyn Galang. Administrator (AD) Mark Cruz arrived shortly after and discussed purpose of the visit with LPA Bentley. AD Mark Cruz has an Administrator certificate pending renewal with a received date of November 22, 2024.

The facility is licensed for age range 60 and over, approved for capacity of six (6) Non-Ambulatory residents, and has a hospice waiver for three (3) residents. There are currently six (6) residents present during today’s visit. The facility is a two-story house of which second story consists of: 4 bedrooms, and 3 bathrooms which are utilized for caregivers. The first floor consists of: 4 resident bedrooms; of which 2 bedrooms are shared bedrooms and 2 are private bedrooms, 3 bathrooms for staff and residents, living room, dining area, and kitchen. There is a sun room in the back of the facility next to dining area used as an activity room and for family visitations.

LPA Bentley toured the interior and exterior of facility with AD Cruz. and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the residents’ personal belongings were observed in residents’ closets. Additional bed linens, comforters, and bath towels were available during the visit. The water temperature in 3 of 3 resident bathrooms were measured to be between 101.2 and 129.5 degrees Fahrenheit. This poses an immediate risk to residents in care. (SEE LIC 809-D) Grab bars and non-slip mats were observed in all resident bathrooms.

The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the stove. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed. CONTINUE TO LIC-C PAGE....
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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Document Has Been Signed on 03/10/2025 03:57 PM - It Cannot Be Edited


Created By: Eboni Bentley On 03/10/2025 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MILES PLACE OF FOUNTAIN VALLEY 2
FACILITY NUMBER: 306006113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in three out of three bathrooms. The water temperature in three common client bathrooms tested at 101.2 degrees F in Bathroom 1, 128.1 degrees F in
bathroom 2, and 129.5 degrees F in bathroom 3, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Licensee will obtain the correct temperature gauge on all three faucets and maintain a temperature log testing temperatures every two hours from 5pm on March 10, 2025 to 5pm March 11, 2025. Licensee stated they will submit water temperature logs to CCLD via email to eboni.bentley@dss.ca.gov by 5pm on POC due date of March 11, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


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: MILES PLACE OF FOUNTAIN VALLEY 2
FACILITY NUMBER: 306006113
VISIT DATE: 03/10/2025
NARRATIVE
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LPA observed three fire extinguishers mounted and charged in garage, kitchen, and hallway area, which were last serviced on March 5, 2025. LPA observed and tested carbon monoxide and smoke alarms which all operational. A record review reveals fire drills are being conducted quarterly with the last drill on January 25, 2025.

The attached 2-car garage was observed clean and walkways were free of clutter and debris. A washer and dryer were found in working condition. LPA Bentley observed an adequate amount of emergency food and water supply. The backyard was clean and free of clutter and debris. The exit gate on the exterior of the home was self-closing and self-latching, and in operating condition.

LPA conducted a review of six residents (R1-R6) service files and five (5) staff (S1-S5) personnel files revealed to be complete. Facility has liability insurance on file effective May 15, 2024 through May 15, 2025. A review of the Medication Records Administration (MAR) was conducted and found to be within Title 22 California Code of Regulations. LPA Bentley interacted with and interviewed 6 of 6 residents during facility tour.

Based on the observations made during today’s visit; the facility is being cited per Title 22 Division 6 of the California Code of Regulations

This report was read and reviewed with (AD) Mark Cruz, and a copy of this report and Appeal Rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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