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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006446
Report Date: 07/01/2024
Date Signed: 07/01/2024 05:12:49 PM

Document Has Been Signed on 07/01/2024 05:12 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PERPETUAL LOVE SENIOR LIVINGFACILITY NUMBER:
306006446
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, FREGILFACILITY TYPE:
740
ADDRESS:18480 SANTA ALBERTA CIRCLETELEPHONE:
(714) 332-7051
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
07/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Fregil JimenezTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Edward Kim and Licensing Program Manager (LPM) Lourdes Montoya conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Kim and LPM Montoya met with Applicant Fregil Jimenez and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing Division (CCLD) on November 6, 2023. The applicant requested a capacity of 6 nonambulatory residents and of which one (1) bedridden. Applicant has requested a hospice waiver for two (2) residents. Facility phone number (714)968-6042. LPA Kim and LPM Montoya observed the following.

Structure:
The facility is a one story house with an attached 2 car garage with five (5) bedrooms (1 is for staff), 2 full bathrooms, family room, dining room, a kitchen, and living room with a screened fireplace. There are 6 exits, one exit door in the family room, the exit in the front door, the exit in bedroom 1, the exit in bedroom 2, the exit in bedroom 3 which is approved for 1 bedridden resident, and the exit in bedroom 4.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Bedrooms:
There are four (4) Resident Bedrooms. There are 3 private resident bedrooms and 1 shared bedroom (#4). The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings. Bedroom 5 is designated as the staff bedroom

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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 4
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: PERPETUAL LOVE SENIOR LIVING
FACILITY NUMBER: 306006446
VISIT DATE: 07/01/2024
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Bathrooms:
All bathrooms have a working toilet, wash basin and walk in shower. All bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in linen closet in the hallway.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Sample menus posted and available.

Food Service:
There are residents living in the facility at this time. There is 2-day perishable food and 7-day non-perishable food supply on hand.

Smoke Detectors/Carbon Monoxide Detectors:


Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There are fire extinguishers mounted on the wall in the dining area, and one mounted in the hallway next to the resident room 3 and resident room 4. All fire extinguishers are fully charged and serviced on April 5, 2024.

Appliances:
There is one 4 electric burner stove, 1 oven, microwave oven mounted above the stove, a refrigerator, dishwasher, washer, and dryer.

Toxins:
All cleaning supplies and chemicals are kept in two areas: kitchen cleaning supplies locked under the kitchen sink and all extra cleaning supplies are locked in the garage..

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
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: PERPETUAL LOVE SENIOR LIVING
FACILITY NUMBER: 306006446
VISIT DATE: 07/01/2024
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Water Temperature:
Hot water was measured in all bathrooms. Hot water measured in private bathroom at 112.1 degrees Fahrenheit and shared bathroom at 115.7 degrees Fahrenheit.

Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in dresser next to the dining room. The first aid kit has all the required elements. Medications will be stored in the closet in the hallway next to bedroom #1.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in the closet next to bedroom 1..

Reading Material, Games, Equipment & Materials:
Arts and craft, tablet, and board games are stored in the family room.

Fire clearance:
Fire Clearance approved by Fountain Valley Fire Department inspector Thang Nguyen on December 14, 2023.

Component III:
Component three will be discussed on next visit.

During the pre-licensing inspection, certain items were observed which do not comply with applicable laws and regulations: the following items must be corrected and proof of correction shall be submitted to the CCLD office attention of LPA Edward Kim via email to edward.kim.@dss.ca.gov. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow-up inspection verification of corrections.

1) Furnace has an open flame and is not strapped securely and needs follow up with Socal Gas.
2) Electric stove front left burner is not operable.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: PERPETUAL LOVE SENIOR LIVING
FACILITY NUMBER: 306006446
VISIT DATE: 07/01/2024
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An exit interview was conducted and a copy of this report has been provided to Applicant Fregil Jimenez. LPA Edward Kim will submit a copy of the facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

END OF REPORT
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4