<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000589
Report Date: 11/02/2022
Date Signed: 11/02/2022 11:59:50 AM


Document Has Been Signed on 11/02/2022 11:59 AM - 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:BRIGITTE'S VILLA REGINA HOMEFACILITY NUMBER:
306000589
ADMINISTRATOR:MARK FISKFACILITY TYPE:
740
ADDRESS:24331 SPARTANTELEPHONE:
(949) 770-2702
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mark FiskTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was screened for symptoms of Covid-19 and granted entry by staff. LPA observed there was no See Something Say Something Poster (PUB 475) posted in the main entry way of the facility. LPA observed the PUB 475 poster is 8 1/2 by 11 inches in size and is posted in the dining room. LPA met with Administrator Mark Fisk, his Administrator's Certificate expires on 1/26/2024. The facility is a 7 bedroom (1 is for staff) single story home with 4 bathrooms, kitchen, dining room, living room and a 2 car attached garage. The garage is kept locked and used for storage. LPA observed the ktichen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the knives and sharp objects are kept secured and inaccessible to residents. The soap and laundry supplies are kept locked in the laundry room. LPA observed the medications are kept locked in the laundry room. LPA observed all the resident rooms had the required furnishings. LPA observed all bathrooms were clean and operational. Smoke detectors and carbon monoxide detectors tested operational. LPA observed the fire extinguisher in the kitchen is fully charged. LPA inspected the first aid kit. The first aid kit has all the required elements. LPA toured the backyard. No bodies of water observed. LPA observed a sitting area with an umbrella. The exit gate is operational. No obstacles or hazards observed. No deficiencies observed during the visit. LPA consulted with the Administrator concerning reporting requirements and continued Covid-19 mitigation. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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 1