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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612905
Report Date: 10/28/2024
Date Signed: 10/28/2024 01:44:15 PM

Document Has Been Signed on 10/28/2024 01:44 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:BATES FAMILY HOMEFACILITY NUMBER:
300612905
ADMINISTRATOR/
DIRECTOR:
RANDALL BATESFACILITY TYPE:
735
ADDRESS:26522 MIMOSA LANETELEPHONE:
(949) 716-8713
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Randall Bates, Administrator5TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of an annual inspection. LPA was greeted and granted entry by administrator Randall Bates after explaining the purpose of the visit.

The facility is an Adult Residential Facility licensed for six ambulatory clients. Currently there are three clients in care. The facility is a two-story home with four bedroom including the staff room on the upper level along with a shared bathroom. The living room, kitchen, laundry area and a half bath are located downstairs. There are one shared and one single bedroom occupied currently.

Facility appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for all four clients. Hot water measured at 110 degrees Fahrenheit in both bathrooms. LPA observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food was available as required by regulations. LPA observed hallways and walkways were free of obstruction.

LPA observed the fire extinguishers on both levels are charged and have been maintained. Staff and LPA tested smoke and carbon monoxide detectors which were found to be operational. Cleaning products and sharp instruments are stored in a locked cabinet in the kitchen. Medication for each client is kept locked and secured in the downstairs bathroom. The backyard has one shaded seating area, and the exit gate is unlocked and unobstructed. No bodies of water observed. LPA reviewed all three clients’ files and medications as well as P&I records which were verified to correspond to the amount noted on the ledger.

LPAs reviewed three staff files. All files of staff and clients contained all required documentation. All current staff members are cleared and associated.

CONTINUED ON FORM LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BATES FAMILY HOME
FACILITY NUMBER: 300612905
VISIT DATE: 10/28/2024
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CONTINUED FROM LIC809
The administrator certificate renewal has been submitted and was verified to be pending for both administrators. The Emergency and Disaster Plan was reviewed. However the last documented emergency and fire drill took place in September 2023 with no quarterly drills conducted since. A type B citation issued on an attached form LIC809-D.

No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility staff.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 01:44 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 10/28/2024 at 01:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BATES FAMILY HOME

FACILITY NUMBER: 300612905

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records reviewed, the licensee did not comply with the section cited above as the last documented drill was dated September 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee will conduct one drill and provide documentation thereof to LPA prior to the plan of corrections due date, along with a schedule for the upcoming quarterly drills.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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