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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000639
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:32:42 PM

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:GRANNY'S PLACE IIIFACILITY NUMBER:
306000639
ADMINISTRATOR:SIMPSON, RONALD P.FACILITY TYPE:
740
ADDRESS:24695 DORIA AVENUETELEPHONE:
(949) 598-9466
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
09/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Ernesto Dellima and Delia PardoTIME COMPLETED:
11:45 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 by Caregiver Ernesto Dellima and explained the reason for the visit. Administrator Delia Pardo arrived during the visit.

At 10:00 AM, LPA toured the facility with Administrator Pardo. Facility has 6 residents in care during today's visit. 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 as well as restrooms stocked with soap/ sanitizer. All rooms are double occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed the shaded outside visitation area as well as a pool secured with a fence. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six resident files during the visit and all files are up to date including emergency information. All residents and staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of documenting visitor temperatures as well as symptom status. Additionally, LPA consulted with Administrator regarding the importance of hand washing signs in all the restrooms.

No deficiencies noted during today's visit. An exit interview was 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: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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