306000639-8-15-2022-22-AS-KSGH-CHBV22-20220815160224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000639
Report Date: 08/15/2022
Date Signed: 08/15/2022 04:02:33 PM

Document Has Been Signed on 08/15/2022 04:02 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:	GRANNY'S PLACE III		FACILITY NUMBER:	306000639
ADMINISTRATOR:	SIMPSON, RONALD P.		FACILITY TYPE:	740
ADDRESS:	24695 DORIA AVENUE		TELEPHONE:	(949) 598-9466
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	08/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Ronald Simpson, Licensee Ernesto Dellima, caregiver Anita Macaraeg, caregiver Delia Pardo, Administrator		TIME COMPLETED:	04:15 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	On 08/15/2022 at 2:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by caregiving staff after being temperature checked and signing in. LPA explained the purpose of the visit. Caregiving staff called administrator Delia Pardo to notify her of the visit. Administrator arrived shortly afterwards to assist with the visit. Licensee Ronald Simpson also arrived at the final stages of the visit and signed this report. At approximately 3:00pm, LPA accompanied by administrator toured the physical plant of the facility. LPA observed a check-in station where visitor temperatures are being documented. There are currently five (5) residents in care, one (1) of which is receiving hospice care. The residents are observed relaxing in the common area or in their respective bedrooms and appear clean and well taken care of. The four (4) bedrooms include all necessary components. An ample supply of linen is observed. The bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are stored in a kitchen drawer secured by a magnetic lock. LPA observed a sufficient supply of food and water present, as well as emergency rations and water stored in the attached garage. A 30-day supply of medication as well as PRN is centrally stored in a laundry room cabinet secured by magnetic locks. The medication pre-poured for the day is locked in a different cabinet located in the kitchen. Cleaning supplies are located in the locked attached garage. LPA observed the facility has COVID-19 Precautions posters and all required department postings as well as hand-washing signs in the bathrooms. However the administrator certificate for two of the administrators are an outdated copy, which the licensee will update shortly. The facility has an adequate supply of PPE. A fire extinguisher is present and charged. The facility's Infection Control Plan has been submitted by licensee to the Department on 06/29/2022. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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: GRANNY'S PLACE III	FACILITY NUMBER: 306000639
	VISIT DATE: 08/15/2022

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CONTINUED FROM FORM LIC809

Caregiving staff present is correctly cleared and fingerprinted in Guardian, however caregiver Anita Macaraeg is only showing a staff association for Granny's Place IV (license #306003560). LPA toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture is present for the enjoyment of residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There is a fully fenced swimming pool in the backyard.

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. One Technical Advisory is being issued regarding staff association. This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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