306006142-8-10-2022-22-AS-CDPO-CH6QJ6-20220810121214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006142
Report Date: 08/10/2022
Date Signed: 08/10/2022 12:12:23 PM

Document Has Been Signed on 08/10/2022 12:12 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MONROY HOME CARE ASSISTANCE		FACILITY NUMBER:	306006142
ADMINISTRATOR:	DURAN, WENDY K.		FACILITY TYPE:	740
ADDRESS:	24322 FORDVIEW STREET		TELEPHONE:	(714) 353-6133
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	08/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Facility Administrator- Wendy Duran		TIME COMPLETED:	12:30 PM

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Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an announced pre-licensing visit and was greeted by Facility Administrator (AD) Wendy Duran and Licensee Olga Fabiola “Favi” Lugo. Prior to being granted entry into the facility, AD Duran took LPAs temperatures and conducted sign-in. LPAs observed the Administrator's Certificate for Wendy Duran which expires on 1/19/2024 and is posted at the entrance at the facility.

Facility is undergoing a change in ownership. Previous license for facility: "A Mission Residential Care for the Elderly" has been approved for 6 non-ambulatory residents, of which 2 may be on hospice and 0 may be bedridden.

LPAs De Perio and Marin toured the interior and exterior portions of the facility with AD Duran and Licensee. For today’s visit, LPAs observed a total of 4 residents in care of which 1 is on hospice, and a total of three staff on duty of which all have been cleared and associated to facility.

Structure: Facility is a 2 level structure. On March 23, 2022, the Orange County Fire Authority granted a fire clearance for a capacity of 6 non-ambulatory residents. Facility has requested to be granted licensure for 6 non-ambulatory residents of which 6 may be on hospice and and 0 bedridden. There are a total of 3 shared bedrooms, which there are no single rooms. The upper level is utilized for staff members and not for resident use.

Bedrooms: All three bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free.

Bathrooms: The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 105 degrees Fahrenheit and hand washing signs were observed.

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SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MONROY HOME CARE ASSISTANCE	FACILITY NUMBER: 306006142
	VISIT DATE: 08/10/2022

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Linens and Hygiene Supplies: Facility has an adequate supply of linens is stored inside the facility and in the garage.

Posters, Emergency Phone Numbers, Exit Plan: LPAs observed the COVID-19 precautionary signs posted, along with the PUB475 "See Something, Say Something" poster. Emergency disaster plan is posted at the entrance of the facility.

Food Service and Menu: Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Facility had back-up emergency food and water supply located in the garage.

Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide detectors were tested and operational. Smoke alarms were observed to be located in both levels of the facility.

Alarms: There are auditory alarms located on every door of the facility, of which all were tested and operational. LPAs also observed that each resident and bathroom has a call button, which is alerted throughout the facility when pressed.

Fire Extinguisher: Fire extinguishers are located in multiple areas of the facilities and observed to be charged and mounted.

Appliances: Stove is a four-burner induction stove, there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the garage.

Toxins: Toxins and disinfectants are locked in the garage and inaccessible to residents.

Medications, PPE First-Aid Kit and Manual: LPAs observed that First Aid Kit had all the required components. Medications were locked in a cabinet located in the living room. Facility had an adequate supply of PPE located inside the facility and in the garage.

Backyard: No bodies of water were observed. There are 2 exit gates in the backyard, and facility will ensure that both gates are self-latching and self-closing. LPAs observed two patio areas with adequate shading.

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SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MONROY HOME CARE ASSISTANCE	FACILITY NUMBER: 306006142
	VISIT DATE: 08/10/2022

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Resident and Staff Files: Records were kept in a cabinet located inside the facility.

Recreational Activities: The facility has activities that commensurate with plan of operation.

LPAs De Perio and Marin verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Duran and Licensee. LPAs discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA Marin reviewed the Component III with AD Duran and Licensee.

Per interviews, Licensee and Administrator stated that they are not planning to advertise for special dementia program for this facility as of this time.

Prelicensing visit and Component III are now complete. LPAs will provide copy of this report to Centralized Applications Bureau for review and final determination of the application.

LPAs advised AD Duran Licensee to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries.

LPA De Perio conducted an exit interview with AD Duran and Licensee Favi and a copy of this report was provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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