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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605363
Report Date: 02/28/2022
Date Signed: 02/28/2022 03:57:26 PM


Document Has Been Signed on 02/28/2022 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VILLA REGINA IIIFACILITY NUMBER:
300605363
ADMINISTRATOR:MARK FISKFACILITY TYPE:
740
ADDRESS:24832 ARGUSTELEPHONE:
(949) 295-9191
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Erin Fisk and Brigitte FiskTIME COMPLETED:
10:48 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Erin Fisk and Licensee Brigitte Fisk arrived during the visit.

At 9:05 AM, LPA toured the facility with Administrator Erin Fisk. Facility has 6 residents in care during today's visit with 1 resident on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet/ questionnaire. Facility takes resident and staff temperatures daily and documents. LPA observed the first aid kit has required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food. LPA observed the shaded outside visitation area. Exit gate is unlocked. LPA observed the locked medication area. Facility does not use a medication administration record. Facility does a monthly audit of medications. Facility provides activities in the form of exercise and games and LPA observed residents participating in exercise. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files are up to date including emergency information. ALL residents and all staff are vaccinated for Covid-19.
LPA consulted with Licensee and Administrator regarding the importance of maintaining an ample supply of PPE and emergency water on-site at the facility.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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