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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612905
Report Date: 08/29/2022
Date Signed: 08/29/2022 05:19:39 PM

Document Has Been Signed on 08/29/2022 05:19 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:BATES FAMILY HOMEFACILITY NUMBER:
300612905
ADMINISTRATOR:RANDALL BATESFACILITY TYPE:
735
ADDRESS:26522 MIMOSA LANETELEPHONE:
(949) 716-8713
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Randall Bates, Administrator
Lorna Cole, caregiver		TIME COMPLETED:
05:30 PM
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On 08/29/2022 at 2:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct a required annual inspection. LPA rang the bell and knocked multiple times before the door was answered by a relative of the licensee, present to pick up some belongings. Relative indicated that staff was absent while clients were away at their respective day programs and that both staff and clients would return approximately around 4:30pm. LPA contacted the mobile phone number on file and left a voicemail but was unable to reach licensee directly.

At approximately 4:15pm, LPA returned to the facility and was greeted by caregiver Lorna Cole, caregiver after explaining the purpose of the visit. Administrator Randall Bates arrived shortly afterwards to assist with the visit.

LPA toured the ground level of the physical plant with the caregiver present then toured the upstairs area with the administrator. There are currently five (5) clients in care, all of which are ambulatory.

The residents are observed coming back from the adult day program and relaxing in the common area or in their bedroom and appear clean and well taken care of. The three (3) bedrooms include all necessary components. An ample supply of linen is observed. The shared bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Staff present is adequately cleared and associated in Guardian. The fire extinguishers present are mounted and charged. They have been serviced in October 2021.
Sharp instruments are stored in a kitchen cabinet secured by a key lock. The centrally stored medication and resident files are located in a locked cabinet in the ground level half bathroom. LPA observed a sufficient supply of food and water present.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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: BATES FAMILY HOME
FACILITY NUMBER: 300612905
VISIT DATE: 08/29/2022
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CONTINUED ON FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area is present for the enjoyment of clients and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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