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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006413
Report Date: 03/19/2024
Date Signed: 03/19/2024 10:41:59 AM

Document Has Been Signed on 03/19/2024 10:41 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:A TOUCH OF CARE SENIOR HOMEFACILITY NUMBER:
306006413
ADMINISTRATOR:AVILA, MARIA JASMINFACILITY TYPE:
740
ADDRESS:17421 LAURIE LANETELEPHONE:
(714) 609-2303
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 0DATE:
03/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Jasmin Avila - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Andrea Mendivil made an announced visit to conduct a pre-licensing inspection. LPA identified themselves and discussed the purpose of the visit with Licensee Maria Jasmin Avila an initial application to operate a Residential Care Facility for the Elderly application was received by CCL on September 8, 2023 for a capacity of six residents 5 non-ambulatory and 1 bedridden.
LPA Mendivil along with Licensee toured the facility at 9:05AM and observed the following:
Structure: Facility is a single story, 7 bedroom, 3 bathroom house with an attached garage and an off white exterior. The exit gates are unlocked and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All 6 residents rooms are for single occupancy. 1 staff bedroom was observed. All of the rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Resident bathrooms have a working toilet/ wash basin. Staff bathroom has a working toilet/wash basin. .Linens & Hygiene Supplies: Facility has bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in dining room of the facility. Food Service: Licensee has 2 day perishable and 7-day nonperishable foods. Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested and operational. Fire extinguisher present in entry of facility. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: LPA observed a secure area for sharps and toxins. Water Temperature: LPA tested hot water and it read as following: residents bathrooms read at 111.3 and 117 degrees, , residents sinks in bedrooms #1 and #2 read at 109.7 and 106.1 degrees kitchen read at 108.1 degrees. Emergency Supplies: LPA observed supply of emergency water and food. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 03/19/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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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: A TOUCH OF CARE SENIOR HOME
FACILITY NUMBER: 306006413
VISIT DATE: 03/19/2024
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Medication is stored in a locked kitchen cabinet. Facility to use a medication administration record. Resident & Staff File: Records are stored in a locked cabinet.. Reading Material, Games, and Equipment: . LPA observed games and books in facility. Backyard: LPA observed a shaded area for residents. Fire Clearance: Approved for 5 non- ambulatory and 1 bedridden resident on November 9, 2023.

Facility is ready to be licensed. Component III completed. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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