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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600104
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:58:13 PM

Document Has Been Signed on 10/25/2022 03:58 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MIRADA MANORFACILITY NUMBER:
198600104
ADMINISTRATOR:ROBERT TALENSFACILITY TYPE:
735
ADDRESS:14926 COSTA MESA DRTELEPHONE:
(714) 994-4749
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 3DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Administrator Robert Talens TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Robert Talens and the purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (3) client records, (3) staff files, and (3) client medications. Currently the facility has (3) clients which are ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. The Facility is a one story residential house consists of (3) client bedrooms, (2) bathrooms, living room, dining room, kitchen, family room, laundry room, covered patio with table and chairs and a garage. All rooms are clean and in good repair. LPA observed the following during inspection of client rooms: mattresses and box springs in good condition, adequate lighting present, plenty of dresser/closet space present, and all bed linens present. LPA observed there were sufficient bedding, linens, and toiletries accessible to clients. Bathrooms were found to be within Title 22 regulation. Bathroom water temperatures between required 105-120 degrees. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector and smoke detectors are operational. Fire extinguishers were fully charged and operational, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked an in order. Outside grounds were toured and no bodies of water were observed. Patio furniture with umbrella was accessible. Exits/ Walkways around the home were free of debris and hazards. LPA completed visit with the Inspection Tool focused on Infection Control.

No deficiencies cited on this visit and a copy of report was furnished
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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