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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000692
Report Date: 05/31/2022
Date Signed: 05/31/2022 04:24:13 PM


Document Has Been Signed on 05/31/2022 04:24 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:GOOD SAMARITAN GUEST HOME IIIFACILITY NUMBER:
306000692
ADMINISTRATOR:LEO / SUSAN CAMBIOFACILITY TYPE:
740
ADDRESS:26821 VIA GRANDETELEPHONE:
(949) 348-8967
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:5CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Leonardo Cambio, AdministratorTIME COMPLETED:
04:45 PM
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On 05/31/2022 at 3:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Leonardo Cambio, Administrator after explaining the purpose of the visit. LPA observed a check-in station in proximity to the facility entry point used for visitors.

At approximately 3:50pm, LPA accompanied by administrator toured the inside and outside of the facility. There are currently four (4) residents in care. Residents are observed relaxing in the common areas or in their bedroom and appear clean and well taken care of. The three (3) bedrooms include all necessary components. 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 cabinet with a key lock. LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. Cleaning supplies are secured in the locked attached garage and laundry room. A Technical Advisory is however issued in regard to cleaning supplies being stored in the shared bathrooms and unlocked staff bedroom. An ample supply of linen is observed also. LPA observed the facility has COVID-19 Precautions and required department postings. Facility has an adequate supply of PPE. LIC808 Mitigation Plan has been submitted. Staff present is adequately cleared in Guardian.
LPA toured the outside of the facility and observed it to be free of obstructions. LPA observes a shaded area with patio furniture used by residents 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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